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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10123 | 10123 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 463 | J | R87Z11 | On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to ensure that all components of the nurse call system were operational. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light to room 712 was blinking on and off with no sounds. The call light to room 715 was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights to rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room 715 to turn off the call light for room 701. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms 718 and 719, located in a corner, not readily visible to the staff from the halls. When asked how long problems existed on the unit with the call lights CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room 701 called for a CNA to go to room 717 due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room 717 was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:25 PM Licensed Practical Nurse (LPN) #1 reveale… | 2014-04-01 | ||
| 10124 | 10124 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 490 | J | R87Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey and the facility administrative staff was aware of problems with the call lights. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light for room [ROOM NUMBER] was blinking on and off with no sounds. The call light for room [ROOM NUMBER] was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights for rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room [ROOM NUMBER] to turn off the call light for room [ROOM NUMBER]. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms [ROOM NUMBERS], located in a corner, not readily visible to the staff from the halls. When asked how long problems with the call lights had existed on the unit CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observe… | 2014-04-01 | ||
| 10125 | 10125 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 280 | D | R87Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review the facility failed to assure a resident's care plan was reviewed and revised to reflect the current status of one of one resident reviewed with socially inappropriate behaviors. Resident #1 alleged that a new Certified Nurse Aide (CNA) hit him in the eye. Resident #1's care plan was not updated to reflect the allegation and no new interventions were initiated to attempt to address the behaviors. The findings included: The facility admitted Resident #1 on 11/14/2007 and readmitted him on 11/14/2008 with [DIAGNOSES REDACTED]. During record review for Resident #1 on 12/06/2010 the Nurse's Notes dated 11/11/2010 stated, "Resident called nurse to room and states, 'look what the new CNA did to me'. Nurse asked what did CNA do resident states 'CNA punched me in the face'. SA (screening assessment) done noted bluish injury to (R) (right) eye..." Review of the resident's care plan dated 08/17/2010 identified Socially inappropriate/disruptive behavior and Resistance to care, restlessness, crawling on the floor, history of combative behavior...w (with) potential for self-inflicted injury as problems. The care plan had not been updated following the 11/11/2010 incident related to the allegation that the CNA punched him in the face. No new interventions were initiated to address the resident's behavior or the alleged response of a staff member to the continuing behaviors. The care plan included a statement under the problem area dated 11/12/2010 "continue problem x 3 months". | 2014-04-01 | ||
| 10126 | 10126 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2011-01-26 | 281 | D | ZGHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review, observations and interviews, the facility failed to assure that licensed staff appropriately handled narcotics. Two licensed practical nurses (LPN) failed to appropriately count narcotics at the change of shift. Liquid [MEDICATION NAME] was left unattended on a resident's bedside table for an unknown period of time. That resident (Resident #2) was sent to the emergency room with a change in condition. The findings included: The facility readmitted Resident #2 on 3/10/2010 with [DIAGNOSES REDACTED]. Record review revealed the resident was receiving [MEDICATION NAME] 7.5/500 milligrams 1-2 tablets every 6 hours for pain. The resident was also receiving [MEDICATION NAME] for anxiety nightly. Residents #2 and #3 sampled as a result of a facility reported incident dated 1/9/2011 related to an allegation against Licensed Practical Nurses (LPN) #2 and #3. The initial 24 hours report stated, "medication left at bedside on Saturday 1/8/2011. A thorough investigation was implemented immediately. The incident was reported to the administration at 2:08 PM." Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nurses was notified on 1/8/2011 at 2:08 PM. The report indicated that the resident (#2) was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were "nurse in attending to resident and found liquid [MEDICATION NAME] at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident was "narcotics are counted and reconciled at shift change." Immediate corrective action taken was that LPN #1 was "suspended immediately and will not return t… | 2014-04-01 | ||
| 10127 | 10127 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2011-01-26 | 431 | D | ZGHV11 | On the days of the complaint inspection based on interviews, review of the facility's investigation and review of the facility's policy on Drug Storage, the facility failed to assure narcotics were securely and safely stored. A bottle of Roxanol was found at a resident's bedside with 13.5 milliliters (ml) missing. The findings included: Review of the 24 Hour Report dated 1/9/2011 revealed neglect was alleged against Licensed Practical Nurse (LPN) #2. The description of the incident was "medication left at bedside on Saturday 1/8/2011. An investigation was implemented immediately. The incident was reported to the administration at 2:08 PM. Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nursing (DON) was notified on 1/8/2011 at 2:08 PM. The report indicated that Resident #2 was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were "nurse in attending to resident and found liquid Morphine at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident were 'narcotics are counted and reconciled at shift change.' Immediate corrective action that was taken was LPN #1 was "suspended immediately and will not return to employment and license will be reported to LLR per protocol. 100% audit of narcotics in 4 of 4 medication carts was conducted. 100% of licensed staff was re-inserviced regarding securing and accounting for narcotics. Hazardous material re-inservice was done with 100% of staff." The Summary of Incident was "Nurse violated standard of practice related to securing medication." Review of the Timeline related to the incident provided by the facility revealed the resident was found lethargic and unintelligible at 1 PM per the nurse's notes. At 1:21 PM, the amb… | 2014-04-01 | ||
| 10128 | 10128 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 250 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 14 residents reviewed for social services. Resident #16 failed to receive medically related social services for discharge planning and lost personal items. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. The resident was noted in the Resident Assessment Profile as being a short term rehabilitation resident, planning to return to home. The social service note dated 6/7/10 (admitted ) stated that the resident was living in an apartment alone at Pickens County disability prior to hospitalization and that" the goal is to d/c (discharge) home on 31st day. " Social service notes stated, "will visit on reg. 1:1 basis to observe moods and adjustment to placement." The social service notes contained 5 more entries -6/14/10, 6/21/10, 6/24/10, 7/6/10, and 8/3/10. None of the entries addressed discharge planning or assessment for the resident's plan to return home. There was no indication in the documentation that the social services director had talked with the resident regarding the plans to return home and no documentation that he/she had helped the resident with planning for the discharge to home. The information in the social services notes addressed areas,such as; the resident's mood, appetite, weight, and activities. There was no mention of the arrangements to prepare for a move back home, although the 31st day had passed on July 1, 2010. There was no documentation as to why the resident's discharge date had been extended. In review of the resident's current… | 2014-04-01 | ||
| 10129 | 10129 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 514 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews the facility failed to maintain accurately documented records for 3 of 18 records reviewed for accuracy of records. Resident #7 had inaccurate documentation related to the application of a sling, Resident #13 had inaccurate documentation related to the application of ted hose, and Resident #16 had inaccurate documentation of a Grievance/Complaint Report. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. He/she continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director (SSD) and the SSD was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. The Social Services Director in… | 2014-04-01 | ||
| 10130 | 10130 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 164 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies entitled "Competency Catheter Care- Female" (undated) and "Competency Catheter Care-Male" ([DATE]), the facility failed to provide adequate personal privacy for 2 of 2 sampled residents observed for catheter care. Appropriate clothing/draping was not provided for Residents #6 and #8 to prevent unnecessary exposure of body parts during catheter care. Also, based on random observation and interviews, the facility failed to provide privacy/confidentiality during medical/financial communication with Resident #13 in a common area of the facility. The findings included: The facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Prior to beginning catheter care on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 closed the corridor door and pulled the privacy curtain around the resident's bed. Observation revealed the resident lying in bed with a house dress pulled up to the epigastric area. A towel was positioned across the abdomen and perineal area. The resident's legs were bare to her/his ankles except for the disposable brief which was pulled down to the knees. Prior to the treatment, the CNA removed the towel drape and placed it below the resident's feet on the bed, exposing the resident from the epigastric area to the ankles. Resident #6 remained thusly exposed throughout the catheter care, perineal care, positioning on her/his left side, and cleansing of the buttocks and anal areas. The resident was then instructed to "lie back" which she/he did without assistance. Both staff then left the bedside with the resident exposed to wash their hands. They returned to the bedside and assisted the resident to replace the brief and pull down and snap the housedress in readiness to get out of bed. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 had not been draped appropriate… | 2014-04-01 | ||
| 10131 | 10131 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 241 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to promote care in a manner that maintained or enhanced dignity and respect. Staff failed to respect Resident #13's wishes to refuse to sign paperwork and terminate a conversation in a common area which resulted in increased agitation. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, "I'm not going to sign any papers!" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, "Don't touch me!" The staff member continued to ask her/him to sign the paperwork with the resident tearfully yelling out "No!" After the staff member left, Certified Nursing Assistant (CNA) #2 came and sat down next to the resident to talk to her/him. Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A CNA identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today she/he was not in a good mood. The OT stated that the resident would not sign the p… | 2014-04-01 | ||
| 10132 | 10132 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 157 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to notify the responsible party (RP) of changes. For one of five residents reviewed for falls, Resident #3 had a family member who was not notified of a fall with injury. The findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/23/10 at 1:45 PM revealed Resident #3 sitting on her/his bed. She/He had a dark swollen area on her/his forehead along with yellow/black discolorations under her/his eyes. Record Review on 8/24/10 at 11:52 AM revealed Nurse's Notes dated "8/11/10 5P(M) Resident asleep in high back chair + rolled onto floor. Has aprox(imately) 9 cm (centimeter) bruise to forehead. BP (Blood Pressure) 158/84, P(ulse)- 76, R(espirations)- 20, T(emperature)- 97.8. ROM (Range of Motion) (without) difficulty. Assisted to chair. Neuro (checks) WNL (within normal limits). No distress noted". "8/11/10 6 P(M) (Family member) called + notified of fall + injury." "8/11/10 6:15 P(M) Dr.__ notified on voice mail of fall + injury." Review of the Incident/Accident Report on 8/24/10 revealed the following: "Date of Incident/Accident: 8-11-10, Time of Incident/Accident: 5 PM, ...Name of Physician Notified: Dr. __, Date: 8/11/10, Time of Notification: 6:15 PM, Name and Relationship of Family Member/Resident Representative Notified: (Family Member), Date: 8/11/10, Time of Notification: 6 PM". During a phone interview on 8/25/10 at 9:00 AM, Resident #3's family member stated that she/he would be the person who would be notified if the resident's condition changed. The family member went on to state that she/he came in to visit her/his family member one afternoon and found bruises on Resident #3's face. She/He had asked the staff what had happened, but they didn't know. She/He stated that there was a big fuss made because nothing had been documented about it, but that she/he was told that Resident #3 had fallen the night before.… | 2014-04-01 | ||
| 10133 | 10133 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 309 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide care and services as ordered by the Physician for 2 of 18 sampled residents reviewed. The facility failed to ensure that Resident #13, on anticoagulant therapy, did not receive [MEDICATION NAME] after the Physician ordered the medication held due to an elevated PT/INR ([MEDICATION NAME]/International Normalization Ratio). In addition, Resident #13 did not have Ted Hose applied as ordered. Resident #7 did not have a sling applied as ordered by the physician. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 8/24/10 at 9:36 AM revealed a laboratory (lab) report dated 5/17/10. The PT was 37.2 H(igh). The reference range was listed as 9.4-10.8 sec(onds). The INR was 3.9 H(igh). The reference range was listed as .9-1.2 with the suggested therapeutic INR range for venous [MEDICAL CONDITION] and [MEDICAL CONDITION] listed as 2.0-3.0. A handwritten note to the right of the page stated "Dr. __: Hold [MEDICATION NAME]. Redraw PT/INR Thursday 5/20/10 and call to Dr. __during business hrs (hours) Thursday". Review of the Physician's Telephone Orders on 8/24/10 at 12:42 revealed an order to "Hold [MEDICATION NAME], Check PT/INR Thursday 5/20/10, Call results to Dr. __ during business hours Thursday". The Physician's Telephone Order had been dated 5/17/10 and the time next to "Signature of Nurse Receiving Order" was 6:45 PM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 5 mg (milligrams) (1) PO (By Mouth) (at) HS (Bedtime) 9P(M)". The [MEDICATION NAME] had been initialed as having been given on 5/15/10, 5/16/10, and 5/17/10. The [MEDICATION NAME] had been held from 5/18/10 through 5/22/10 and had been discontinued on 5/23/10 according to the MAR indicated [REDACTED] During an interview on 8/24/10 at 3:45 PM, the Director of … | 2014-04-01 | ||
| 10134 | 10134 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 224 | G | 5SHE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record reviews, interviews and review of the facility's Abuse and Neglect policy, the facility failed to assure 3 of 5 sampled residents were free from neglect. Resident #1 and #3's dressings were not changed per the physician's orders [REDACTED]. Resident #2's wound was observed to have a yellow center with dried blood. The findings included: Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. The Annual MDS coded Resident #1 as totally dependent for hygiene, bathing and toileting. Resident #1 was coded as needing extensive assistance with transfers, dressing and eating. No behaviors were coded as occurring during the assessment period. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. The interventions that were in place prior to the incident were "abuse and neglect addressed 10/1/2010 by staff development coordinator." The interventions taken by the facility to prevent future abuse were "facility continues to stress no tolerance for abuse or neglect. Reeducation of staff on abuse/neglect." LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx (treatment) on the opposite hall, and stayed over on Sunday n… | 2014-04-01 | ||
| 10135 | 10135 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 315 | D | 5SHE12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the follow up inspection based on observations, interviews and review of the facility policy on Peri (perineal)-care, Certified Nursing Assistant #1 failed to provide for the dignity of Resident #6 and failed to appropriately provide peri-care for Resident #6. One of two residents observed for peri-care. The findings include: The facility admitted Resident #6 on 12/18/2008 with [DIAGNOSES REDACTED]. During peri-care observation on 2/7/2011, CNA #1 was observed in Resident #6's room removing the resident's pants. The blinds were left open. The curtains were observed to be open as well. The resident's roommate was in bed awake. A grabber was observed in the bed lying along side the resident's left leg. The CNA exposed the resident and wiped the resident's groin and then wiped once down the middle. CNA #2 then closed the blinds and pulled the curtain. CNA #1 then retrieved a clean brief from the resident's closet using the soiled gloves. CNA #1 rolled the resident over onto the metal grabber and placed the clean brief under the resident. CNA #1 still using soiled gloves fastened the brief and dressed the resident. During an interview on 2/7/2011, CNA #1 stated that she did not close the blinds or pull the curtain to provide for the resident's dignity. She also stated that she "forgot" to clean the resident's bottom. CNA #1 confirmed that she did not change her gloves prior to placing a new brief on the resident. CNA #1 stated that she did not recall the last time she was checked off on peri-care competency. Review of the facility's plan of correction revealed that CNA#1 was checked off on competency on peri-care on 1/6/2011. No concerns were noted at that time. Review of the facility's policy on Peri-Care revealed the following:..."3. Provides for privacy. 17. Asks resident to lower legs and assume side lying position. Assists as necessary." | 2014-04-01 | ||
| 10136 | 10136 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 314 | G | 5SHE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to 3 of 5 sampled resident's wounds. Resident #1 and #3 did not have their dressings changed as ordered. Resident #2 had a dressing on her right lower leg dated 12/6/2010; the dressing was observation on 12/20/2010. The findings included: The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. On 11/22/2010 LPN #3 removed dressings from Resident #1's coccyx and right inner ankle dated 11/19/2010; daily dressing changes were ordered. LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse." LPN #3's facility obtained statement dated 11/22/2010 stated, "On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10." Review of the physician's orders [REDACTED]." T… | 2014-04-01 | ||
| 10137 | 10137 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 502 | D | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on limited record review, and interview the facility failed to provide laboratory services to meet the needs of its residents in a timely manner for 1 of 3 residents reviewed for laboratory services. Resident #1 with documented [MEDICAL CONDITION] of the external genitalia; waist and legs had a physician's orders [REDACTED]. The CMP and BMP were not drawn. The findings included: Resident #1 admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed nurses' notes dated 10/06/2010 at 11:00 AM which stated, "...increased [MEDICAL CONDITION] notified Dr. ... N.O. (new order) 40 mg (milligrams) [MEDICATION NAME] IM (intramuscularly) now then 80 mg [MEDICATION NAME] PO (by mouth) BID (twice a day) x 1 week then resume 80 mg [MEDICATION NAME] PO QD (daily), CMP BMP on 10-13-10..." In a telephone interview with the Director of Nurses on 12/15/2010 at approximately 10:00 AM she stated that the CMP and BMP were not drawn, that she thinks the nurse who took the order failed to transfer it to a lab requisition. | 2014-04-01 | ||
| 10138 | 10138 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 157 | G | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review and interview the facility failed to consult the resident's physician regarding persistent pain and swelling following an injury to Resident #2 left arm/hand/wrist. The resident fell on [DATE], the facility notified the physician and an order was obtained for an x-ray of the hand/wrist. Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The findings included: Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NA… | 2014-04-01 | ||
| 10139 | 10139 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 309 | G | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, interview and record review, the facility failed to provide care and services to maintain the highest practicable physical well being for 1 of 3 residents reviewed for a change in condition. Resident #2 injured her left arm/hand/wrist on 11/24/2010, and was not treated for [REDACTED]. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to … | 2014-04-01 | ||
| 10140 | 10140 | MAGNOLIA MANOR - SPARTANBURG | 425091 | 375 SERPENTINE DRIVE | SPARTANBURG | SC | 29305 | 2011-01-14 | 250 | E | JSXU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection based on record review and interviews the facility failed to assure medically related social services were provided for one of five sampled residents. Resident #1 did not have his hearing aides replaced after the facility misplaced them. The social worker also had Resident #1 sign legal documents even though the resident was deemed incapacitated by two physicians. The findings included: The facility admitted Resident #1 on 4/16/2010 and readmitted him on 7/23/2010 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Review Date of 8/22/2010 indicated the resident had short-term memory problems and modified independence in decision making. No behaviors were documented as occurring within the assessment period. Review of the monthly summary dated 12/18/2010 revealed the resident had short-term memory problems. He was also noted to have disorganized thinking with moderately impaired abilities for decision making. The resident was noted to be verbally abusive and had delusions. Review of the resident's care plan revealed "Cognitive Impairment as evidenced by short-term memory loss and confusion at times." Review of the medical record revealed two Decisional Capacity forms. The first was signed by the Vascular Surgeon on 5/19/2010 and by the Attending Physician on 5/27/2010. The second form was signed by the Vascular Surgeon on 7/23/2010 and by the Attending Physician on 8/6/2010. Review of the record revealed that Resident #1's first hearing aide was lost in May and the second one was lost in early June 2010. A Certified Letter was sent to the Resident's first responsible party and to the resident's son on August 10, 2010. The letter included the "Medicare Determination Notice, Community Long Term Care and a form regarding Resident #1's hearing aide replacement. On August 10, 2010 the Social Worker documented that she spoke with the resident's son and he stated, "He was not sig… | 2014-04-01 | ||
| 10141 | 10141 | SUNNY ACRES | 425093 | 1727 BUCK SWAMP ROAD | FORK | SC | 29543 | 2010-12-01 | 225 | D | 07P711 | On the day of the inspection, based on review of facility concern forms and interview, the facility failed to ensure that all allegations of misappropriation of resident property were reported to the State survey and certification agency for 2 of 2 allegations reviewed (Resident A). The findings included: Review of the concerns filed with facility administration since the last recertification survey revealed two allegations of misappropriation from Resident A. On 8/12/10, the resident reported $12.00 missing. Facility staff searched for the money but it was not found. The facility reimbursed the resident. On 9/1/10, Resident A reported $50.00 missing, two twenty dollar bills and other money totaling fifty dollars. A search revealed some one dollar bills in the resident's coat, but she stated this was not part of the $50.00 she had put in her purse. The facility reimbursed the resident by depositing the money in her fund account. The Administrator and Director of Nurses were asked at 4 PM on 12/1/10 if these allegations had been reported to the State survey and certification agency. After researching their files, no evidence was discovered to show the allegations of misappropriation of resident property were reported. | 2014-04-01 | ||
| 10142 | 10142 | GLORIFIED HEALTH AND REHAB OF GREENVILLE, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2010-07-07 | 309 | D | KOJZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide care and services as ordered by the physician. One of fourteen residents reviewed for care and services, Resident # 8, did not receive a follow-up with the oncologist to get biopsy results as ordered. The findings included: The facility admitted Resident # 8 on 6/14/10 with [DIAGNOSES REDACTED]. Record review on 7/6/10 at 2:30 PM of the accumulative physician's orders [REDACTED]. ___ (1) wk (week) for biopsy results". Review of the Physician Discharge Summary dated 6/14/10 on 7/6/10 at 2:37 PM revealed under "Hospital Course", that Resident # 8 was admitted with AMS (Altered Mental Status) s/p (status [REDACTED]. [MEDICATION NAME] on 6/10 with ROSE (Rapid On-Site cytopathologic Examinations) revealing malignancy...Heme/Onc (Hematology/Oncology) was consulted and recommended breast mass biopsy. This was performed on 6/14 by general surgery and final pathology/results pending. (Resident #8) is scheduled to follow up with Dr. ___ in 1 week for these results and to initiate plan of care... (She/He)does need quick follow up for biopsy results with Heme/Onc as this looks like [MEDICAL CONDITION] from preliminary results. (She/He) may be a possible Hospice candidate given her PMH (Primary Medical History) of dementia and other co-morbid conditions". Review of the Physician's Progress Notes, Nurses Notes, and Laboratory results on 7/6/10 revealed no mention of the breast mass biopsy results or an office visit. During an interview on 7/7/10 at 9:15 AM, RN (Registered Nurse) #1 reviewed the June 2010 accumulative physician's orders [REDACTED]. During an interview on 7/7/10 at 11:20 AM, Unit Clerk #1 was asked if they used an appointment calendar to keep track of residents' appointments. She/He stated that Resident #8's appointment was not on her calendar. When asked about how Resident #8 would have been transported to the appointment, she/he stated that EMS… | 2014-04-01 | ||
| 10143 | 10143 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 365 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observations, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 3 sampled residents with an order for [REDACTED]. The findings included: The facility admitted Resident #14 on 4/28/08 with [DIAGNOSES REDACTED]. Review of the medical record on 12/07/10 revealed a current physician's orders [REDACTED]." Review of the physician's telephone orders dated 11/19/10 indicated, "D/C prev. diet. Mech (mechanical) soft, gr (ground) meats...for better tolerance." Review of the Nurses Notes dated 11/19/10 at 1:00 PM indicated, "Difficulty chewing pork chop at lunch - given gr mts (meats) (with) better tolerance." Review of the Dietary Progress Notes dated 11/23/10 revealed, "The resident's diet consistency was downgraded to mech soft (11/19/10)..." Observation on 12/07/10 at approximately 12:30 PM revealed Resident #14 sitting at a table in the dining room in the process of eating lunch. Observation of the resident's plate revealed fish which was cut into pieces. Observation of the diet card on the lunch tray indicated, "Diet regular Texture regular." Observation on 12/07/10 at approximately 5:45 PM revealed Resident #14 resting in bed, and staff was observed to deliver the dinner tray to Resident #14's room. Observation revealed the dinner plate contained sliced roast beef with gravy, and observation of the tray card again revealed "Diet regular Texture regular." The surveyor asked Licensed Practical Nurse (LPN) #3 to review the current orders related to diet, and LPN #3 confirmed that the order was for ground meat. LPN #3 observed the dinner plate at that time and confirmed that Resident #14's meat was not ground. LPN #3 informed staff to hold the dinner plate and stated that another meal with ground meat would be obtained for Resident #14. On 12/08/10 at approximately 10:30 AM, LPN #3 was asked about the process of communicating diet orders to the dieta… | 2014-04-01 | ||
| 10144 | 10144 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2011-03-02 | 514 | D | HLEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews and interviews, the facility failed to maintain accurate, complete, and organized clinical information about each resident that was readily accessible for resident care for 3 of 15 records reviewed for clinical records. For Resident #5 the documentation of allergies [REDACTED]. For Resident # 11 the MDS and Care Plan were not readily accessible and for Resident #7 the Care Plan was not readily accessible. The findings included: The facility admitted Resident #5 on 12/30/10 with the following [DIAGNOSES REDACTED]. The record review on 2/28/11 at 1:45 PM revealed that there were no current Physician order [REDACTED]. The only orders found on the resident's record were dated 12/2010. In an interview with Licensed Practical Nurse(LPN) #1 at that time, she was unable to state where the orders might be or to locate the current orders. The Admissions Director and Facility Consultant #1 attempted to locate the orders for January and February 2011, but were unable to locate the orders. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. While in the process of reviewing the record the MDS and Care Plan were also not found for this resident. LPN #1 was interviewed and did not know where the documentation could be found. The Admissions Director, Director of Nurses, and Consultant #1 all pursued locating the information within the facility. After 3 hours the MDS was not located and a copy had to be printed for the surveyor. At that time the Care Plan was located and provided. The record review on 2/28/11 also revealed a sticker on the front of the chart which stated "allergies [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"No Known allergies [REDACTED]. The facility admitted Resident #7 on 3/13/07 with the following [DIAGNOSES REDACTED]. Record review on 3/1/11 at 9:10 AM revealed that the Care Plan cou… | 2014-04-01 | ||
| 10145 | 10145 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2011-03-02 | 250 | E | HLEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interview, the facility failed to provide documented evidence that sufficient medically-related social services were provided to meet the needs of 3 of 12 sampled residents reviewed for social services. Resident # 6 experienced a significant personal loss and expressed suicidal thoughts, which were addressed by the physician in 2/2011. The last documented social service intervention was November 2010. Resident # 8 had a planned discharge which was to occur on 3/1/11. The resident left unexpectedly on 2/28/11. There was no evidence of the anticipated discharge plans/interventions documented by social services. Resident # 24's social service noted did not include an accurate description of the resident's behaviors, the room change with subsequent change in social work providers, or behavior interventions. The findings included: The facility admitted Resident #6 on 3/24/10 with [DIAGNOSES REDACTED]. A review of the medical record revealed a Physician's progress note dated 2/24/11 that the resident had lost her husband of [AGE] years recently. A follow-up note dated 2/25/11 documented the resident was seen and that grief and tearfulness was normal as a reaction to loss of her husband. A nursing note dated 2/24/11 documented indicated that the resident had stated "I just want to die" during the morning medication pass. Medicine for increased anxiety was given and the resident seemed to be calmer after the nurse talked to her for a while. The Responsible party was notified and she was going to visit. Follow-up monitoring dated 2/27 revealed no signs or symptoms of depression. Documentation by the Facility psychiatrist dated 3/1/11 revealed that the resident was seen. Group therapy and receiving activity out of the facility was discussed. The resident felt very positive about the opportunity to get out and about the opportunity to socialize with new people. The psychiatrist also addressed the va… | 2014-04-01 | ||
| 10146 | 10146 | LANCASTER CONVALESCENT CENTER | 425155 | 2044 PAGELAND HWY | LANCASTER | SC | 29721 | 2010-12-01 | 225 | D | DFSK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, interview, review of the facility's grievance log and review of the facility's policy on Abuse and Neglect, the facility failed to report an injury of unknown origin. On 10/14/2010 a large, dark purple bruise was noted on Resident #5's back and left side of his chest; he was unable to state how the injury happened. There was no documentation to indicate the facility reported the incident as an injury of unknown origin. (1 of 5 sampled residents reviewed) The findings included: The facility admitted Resident #5 on 2/07/2009 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS (Minimum Data Set) dated 7/12/2010 indicated the resident had no memory problems with moderately impaired cognitive skills for daily decision-making. Review of the Nurses' Note dated 10/14/10 at 1:30 PM stated, "large dark purple bruise note L (left) side of chest and back. Res (resident) stated, I don't know it happened..." Review of the "Incident/Accident Report" form signed 10/18/2010 revealed a date of 10/15/2010 as the date a large, dark purple bruise was noted on the left side of the chest and back of Resident #5. The incident report included the statement, "I don't know what happened." There was no documentation that a referral was made to the State Survey Agency. An interview on 12/01/2010 at approximately 10:38 PM with the Administrator and Director of Nursing (DON) confirmed the findings. The Administrator stated they did not feel the bruises were significant enough to make a report. The Administrator further stated it was the facility practice to determine the cause of the bruise instead of reporting. | 2014-04-01 | ||
| 10147 | 10147 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2011-01-26 | 279 | D | M3RJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review, the facility failed to ensure that comprehensive care plans were developed to describe the safety services to be furnished to residents for 2 of 3 residents reviewed who had repeated falls (Residents #1 and #2). The findings included: Resident #1, with [DIAGNOSES REDACTED]. Review of the resident assessments of 11/2/10 and 11/26/10 showed the resident needed total care from the staff with his activities of daily living. The resident did not ambulate. The resident was discharged home with his daughter on 12/20/10 as planned. Review of the medical record revealed the resident fell on [DATE] at 11:30 AM. He was found on the day room floor, sitting in front of the wheelchair. It appeared that he slipped out of the chair. A non slip product was added to the wheelchair seat to prevent further similar occurrences. At 12 noon on 10/30/10, staff coming from the day room heard a noise and they found the resident lying on his right side on the floor. No injuries were assessed. A tab safety alarm was added to his safety precautions. Documentation in the nurses' notes revealed the resident made multiple attempts to get up unassisted on two days. The nurse's note on 11/2/10 at 11:35 AM noted frequent attempts by the resident to get out of his chair. The tab alarm was in place. The 11/20/10 nurse's note at 3:20 PM stated the resident made multiple attempts to get out of his chair and so was assisted back to bed with no further attempts to get up unassisted. The resident's last fall, on 12/12/10 at 6:40 AM, occurred in the day room. Review of the facility's documentation revealed the resident was up early that morning and placed in the day room. The nurse heard a loud noise coming from the day room and found the resident face down on the floor with the wheelchair tipped over, bleeding from a laceration above his right eye. The resident received emergency treatment and returned to the facility. Review of the C… | 2014-04-01 | ||
| 10148 | 10148 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2011-01-26 | 323 | D | M3RJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review, interviews, and review of the facility's investigative materials related to a fall with serious injury, the facility failed to ensure residents received adequate supervision and assistance devices for 1 of 3 residents reviewed for falls (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. Review of the resident assessments of 11/2/10 and 11/26/10 showed the resident needed total care from the staff with his activities of daily living. The resident did not ambulate. The resident was discharged home with his daughter on 12/20/10 as planned. Review of the resident's interim care plan dated 10/26/10 showed the resident at risk for falls related to weakness, poor endurance, and a new environment. Review of the medical record revealed the resident fell on [DATE] at 11:30 AM. He was found on the day room floor, sitting in front of the wheelchair. It appeared that he slipped out of the chair. A non slip product was added to the wheelchair seat to prevent further similar occurrences per the nurse's note. At 12 noon on 10/30/10, staff coming from the day room heard a noise and the staff found the resident lying on his right side on the floor. No injuries were assessed. The post fall assessment by physical therapy recommended a tab safety alarm on the wheelchair. A nurse's note on 11/2/10 stated "... Tab alarm in place." Sporadic nurses' notes after that date stated the alarm was in place. The care plan dated 11/3/10 showed a problem of "At risk for falls related to: Dependency on staff for transfers" and "Hx (history) of fall." The facility's planned approaches to assist the resident with this problem were: "1. Give needed assist with transfers. "2. Encourage resident to call for assistance as needed. "3. Monitor for changes needed in transfer techniques and update therapy for recommendations. "4. Review any falls for patterns. "5. Safety devices as indicated." Documentation in … | 2014-04-01 | ||
| 10149 | 10149 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2011-01-19 | 279 | E | 988C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a Comprehensive Plan of Care which reflected the residents' current status of 3 of 7 sampled residents reviewed for Comprehensive Plan of Care. Resident #4 and Resident #6 did not have an Initial Plan of Care to address [MEDICAL TREATMENT]. Resident #1 did not have an Initial Plan of Care to address a Foley Catheter. The findings included: The facility admitted Resident #1 on 01-08-11 with [DIAGNOSES REDACTED]. Record review on 01-18-11 at 5:15 PM of the Daily Physician order [REDACTED]. Additional record review on 01-19-11 at 3:30 PM of the Initial Plan of Care dated 01-08-11 revealed an Initial Plan of Care for a Foley Catheter had not been developed. During an interview on 01-19-11 at 5:17 PM with Registered Nurse (RN) #1, she, after record review, verified an Initial Plan of Care for a Foley Catheter had not been developed. The facility admitted Resident #06 on 12-29-10 with [DIAGNOSES REDACTED]. Record review on 01-19-11 at 4:00 PM of the Daily Physician order [REDACTED].d.)". Additional record review on 01-19-11 at approximately 4:00 PM of the Initial Plan of Care dated 12-29-10 and updated on 01-11-11 revealed a Plan of Care for [MEDICAL TREATMENT] had not been developed. During an interview on 01-19-11 at 6:00 PM with RN #1, she, after record review, verified a Plan of Care for [MEDICAL TREATMENT] hd not been developed. The facility admitted Resident #4 on 12/24/10 with [DIAGNOSES REDACTED]. Review of the medical record on 1/18/11 revealed Resident #4 received [MEDICAL TREATMENT] treatment three times weekly. Further record review revealed the care plan for Resident #4 did not include [MEDICAL TREATMENT] treatment as a problem area and did not include any treatment objectives or medical care areas related to [MEDICAL TREATMENT] treatment that reflect the standards of current professional practice. This information was shared with the Mini… | 2014-04-01 | ||
| 10150 | 10150 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2011-01-19 | 280 | D | 988C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise a plan of care to ensure care needs were met for 2 of 7 resident care plans reviewed. The care plans for Resident #3 and Resident #4 were not revised and updated after both residents were placed on contact precautions. The findings included: The facility admitted Resident #4 on 12/24/10 with [DIAGNOSES REDACTED]. Review of the medical record on 1/18/11 revealed a physician's orders [REDACTED]." Further record review revealed a positive culture screen for [MEDICATION NAME] Resistant [MEDICATION NAME] reported on 1/08/11. Review of the care plan indicated the care plan was last updated on 1/06/11. The care plan was not reviewed and revised to include Contact Precautions as a problem area after the positive culture and physician's orders [REDACTED]. This information was shared with the Minimum Data Set (MDS) Coordinator on 1/19/11 at approximately 4:30 PM at which time the MDS Coordinator confirmed the care plan was not revised to include Contact Precautions following the 1/08/11 culture screen. The facility admitted Resident #3 on 12/31/10 with [DIAGNOSES REDACTED]. Record review on 1/18/11 revealed that the resident had been placed on Contact Isolation on 1/3/11 and that a care plan for infection/isolation had not been developed. An interview with Licensed Practical Nurse #2 on 1/18/11 at 6:05 PM revealed that if the [DIAGNOSES REDACTED]. An interview with the Care Plan Coordinator on 1/19/11 at 6:30 PM confirmed that a care plan had not been developed to reflect that Resident #3 had been placed on Contact Precautions. | 2014-04-01 | ||
| 10151 | 10151 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2011-01-19 | 502 | E | 988C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to follow a procedure to ensure that expired laboratory testing supplies were not stored with other laboratory testing supplies available for resident testing in 1 of 1 nursing station. The findings included: On [DATE] at 4:10 PM, observation of a cabinet located behind the nursing station revealed 59 - 6.0 ml BD pink top Vacutainer which expired ,[DATE]. During the observation, Licensed Practical Nurse(LPN) #3 verified that the Vacutainer had expired. During an interview with LPN #1 on [DATE] at 4:55 PM, she stated that nurses were responsible for maintaining in- date Vacutainer and that the cabinet was checked weekly. LPN #1 could not provide documentation which confirmed the weekly checks. During the interview, LPN #1 also confirmed that staff does draw blood samples for testing. | 2014-04-01 | ||
| 10152 | 10152 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 371 | F | 4V0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to discard 28 cartons of milk which were expired in the resident's refrigerator in the day room. There was an additional observation of the resident's refrigerator not functioning for six (6) hours on the last day of the survey. In addition, the facility failed to discard nine (9) cans of nutritional supplements that had expired in a cabinet in the nurses station. The findings included: On 2/6/12 at approximately 5:30 PM during observation of the residents refrigerator, three Tru Moo one percent low fat chocolate milk and seven Pet skim milk were found with the expiration date of February 3, 2012. Nine (9) Pet whole milk and nine (9) Pet skim milk were found with the expiration date of February 5, 2012. On 2/7/12 at approximately 9:30 AM, the surveyor observed that the expired milk remained in the residents refrigerator in the day area. Review of the refrigerator cleaning schedule states: "All items are dated and labeled properly, free of all expired items, and temperatures grafted daily. Further review of the schedule revealed the Month of February 2012 was checked off daily. On 2/7/12 at approximately 10:20 AM, Food Service Director verified that the milk was expired. Through interview the Food Service Director stated, " Dietary Aides do the in and outs in the resident's refrigerator. The in and out policy is to put old to front and new to the back." On 2/8/12 at approximately 9:25 AM, the surveyor observed the Speech Language Pathologist Director opening the residents refrigerator to get milk for a resident and the interior light did not come on. Following the observation the surveyor checked the temperature of the refrigerator which read 46 degrees Farenheit and freezer which read 38 degrees Farenheit. Noting the temperature of the freezer, the surveyor checked the ice cream cup which was soft and runny. On 2/8/12 at approximately 2:15 PM, there was an obse… | 2014-04-01 | ||
| 10153 | 10153 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 463 | E | 4V0311 | On the days of the survey, based on observation and interview, the facility failed to ensure the safety of residents by not having resident call systems equipped in two of four common area restrooms which were accessible to residents. The findings included: During a general observation of the environment on 2/6/12 and throughout the days of the survey, observations were made of two restrooms that were unlocked and with no call system in place for residents use. The restrooms were located on the opening of the hallway across from the Physical Therapy and Activity area. Residents who were able to ambulate and propel themselves independently resided at the facility. During an interview on 2/8/12 at approximately 3:35 PM, the Administrator verified the restrooms were accessible to the residents and that there were no call systems in place. | 2014-04-01 | ||
| 10154 | 10154 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 323 | D | 4V0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observation of Room 910 revealed hazardous objects stored on opening shelving in the resident's room. The findings included: The facility admitted Resident #7 on 2/03/12 with [DIAGNOSES REDACTED]. During a tour of resident rooms on 2/07/12 at approximately 10:30 AM, Resident #7 was observed in his/her wheelchair in the hallway. After Resident #7 entered his/her room, the surveyor entered the room and talked briefly with the resident. While in the room, observation of the open shelves on the wall near the resident's bathroom revealed two clear boxes containing multiple bronze/gold-colored small objects. Observation of the end of one of the boxes revealed the word "Ammunition" among the wording on the box. At that point, the resident informed the surveyor that the boxes were his ammunition and that they were a birthday gift. After informing the Director of Nursing (DON) and Administrator of these findings, the surveyor accompanied the DON to the resident's room, and the DON observed the boxes of ammunition. After talking with the resident, the DON informed the resident that the ammunition would need to be removed from the room for safety reasons. After removing the boxes of ammunition from the room, it was determined that the two boxes contained a total of 100 bullets. The DON and Administrator confirmed that the ammunition was given to the resident as a gift while the resident was in the hospital for surgery. Further investigation was necessary to assure that the resident was not in possession of a firearm. Review of the medical record revealed no Inventory of Personal Items list was completed upon admission to the facility. In addition, the hazardous objects stored on the open shelving were not observed/identified until brought to the staff's attention by the surveyor. | 2014-04-01 | ||
| 10155 | 10155 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 309 | E | 4V0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, review of the policy entitled [MEDICAL TREATMENT] and interview, the facility failed to consistently document checking for thrill and bruit of the arteriovenous (AV) graft for Resident #1 used for his [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #1 on 12/26/11 with [DIAGNOSES REDACTED]. Record review of the nurses notes on 2/8/12 revealed the nurses had not consistently documented checking for thrill and bruit of the resident's AV graft. The record review revealed that the thrill and bruit had not been documented for a total of 22 days since the resident's admission to the facility. On 20 days there was documentation of a positive thrill and bruit and there was one day for which no documentation could be found. After sharing this information with the Director of Nursing, the facility did not dispute the findings or provide any additional documentation that the thrill and bruit had been checked. On 2/8/12 review of the facility's policy entitled [MEDICAL TREATMENT] in the section designated as "Post-[MEDICAL TREATMENT] Nursing Responsibilities" revealed..."Assess and document status of access site every four hours and prn (as needed)." At that time the Director of Nursing verified that the policy did not specifically address checking for thrill and bruit of an AV graft for residents receiving [MEDICAL TREATMENT]. | 2014-04-01 | ||
| 10156 | 10156 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 314 | D | 4V0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and review of the facility's policy entitled Dressing Changes, the facility failed to provide necessary treatment and services to promote healing and prevent infection for Resident # 1, 1 of 1 residents reviewed for wound care. The findings included: The facility admitted Resident #1 on 12/26/11 with [DIAGNOSES REDACTED]. On 2/8/12 at 9:49 AM, Licensed Practical Nurse (LPN) #2 was observed performing wound care to 5 wounds for Resident #1. After explaining the procedure to the resident, setting up her supplies and clean field, the LPN cut and removed the soiled dressing from the left knee wound. She removed her gloves, washed her hands and donned clean gloves. She then obtained a non-adherent dressing from a shelf on the wall and opened it. She sprayed the periwound with wound cleanser and rubbed around the periwound several times. She then sprayed the wound bed with wound cleanser and dabbed the bed several times right to left then back from left to right. She applied the clean dressing and applied tape. The LPN then removed the dressing from a posterior lower leg wound and discarded the soiled dressing. She removed her gloves, washed her hands and donned clean gloves. She then removed the soiled outer dressing from the anterior foot and heel of the left foot and discarded them. LPN # 2 sprayed wound cleanser on the periwound and cleaned the medial, lateral and distal periwound areas with several wipes without turning the gauze. Wound cleanser was then sprayed on the wound bed, and the LPN dabbed the wound bed with gauze 3 times, went beyond the wound margin into the periwound area then back into the wound bed. A clean gauze was moistened with Normal Saline and applied to the wound bed and a dry gauze was placed over the moist gauze. She removed her gloves washed her hands and donned clean gloves. The soiled inner dressing from the left heel was removed and discarded… | 2014-04-01 | ||
| 10157 | 10157 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2012-02-08 | 332 | D | 4V0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record reviews, the facility failed to maintain a medication error rate less that 5 per cent. The facility had 2 errors out of 40 opportunities for error resulting in an error rate of 5.0 per cent. The findings included: Error #1: On 2/6/12 at 4:49 PM, Registered Nurse (RN) #1 was observed during the Medication Pass. RN #1 removed 2 [MEDICATION NAME] ([MEDICATION NAME]) 40 milligram (mg) tablets in single dose packs from the Pyxis machine and the dose of the tablets was confirmed by the surveyor. She verified that the dose to be administered was 40 mg. in the Medication Administration Record (MAR) and in the electronic record in the Pyxis. This was confirmed by the surveyor at that time. She continued to Resident #2's room and opened both single dose unit packs and placed the tablets into the souffle cup. She informed the resident that she was giving him 40 mg. of [MEDICATION NAME] and handed him the souffle cup. The surveyor stopped RN #1 at that time from administering the medication. Review of the Discharge Medication Reconciliation Orders Form from the hospital, signed by the physician, revealed the order was for [MEDICATION NAME] 40 mg. 1 tablet by mouth every AM and every PM. During an interview at that time, RN #1 confirmed that she had two 40 mg tablets in the souffle cup for administration and that it was double the amount ordered to be administered. During an interview on 2/7/12 at 8:15 AM, the Director of Nursing confirmed the order was written for [MEDICATION NAME] 40 mg. 1 tablet every AM and every PM. She stated she would have expected the nurse to check the dose of the medication when it was removed from the Pyxis drawer, check it against the MAR and again in the resident's room. Error #2: During observation of the medication pass on 2/7/12 at 9:04 AM, Licensed Practical Nurse (LPN) # 1 withdrew 0.11 milliliters (ml) of [MEDICATION NAME] 20,000 uni… | 2014-04-01 | ||
| 10158 | 10158 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2013-03-07 | 371 | F | 375T11 | On the days of the survey, based on random observations and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Multiple concerns were identified related to cleanliness, food storage, and the lack of appropriate hair restraints. The findings included: During initial tour of the kitchen area on 3/5/13 at 9:30 AM with the Manager of Dining and Kitchen, the following items were observed: the main oven had dark brown dried substances inside the ovens; cabinets, carts, and ovens had a grease-like film on the outside; carts had debre' inside the carts; multiple pans were stored wet on the dry rack; a small cooler by the tray line had multiple racks of food that were unlabeled or undated; the reach in cooler had multiple pans of food unlabeled and undated; the walk-in cooler had 4 pans of jello undated; 1 container of food labeled with date 2/27/13 was outdated; salad items in containers that were uncovered and undated on a cart in the walk-in cooler; trash and debre' noted under racks near the walls of the walk-in cooler and freezer. It was also noted the kitchen floor had a heavy grease build-up; there was no trash can with a pedal by the handwashing sink; a large uncovered trash barrel near the tray line and a deep fryer with very dark oil and crumbs floating on top of the oil. The Manager verified the deep fryer could not have been cleaned on Sunday as per the cleaning schedule. There were bags of grapes stored in the walk-in cooler not sealed. One kitchen employee had hair not completely covered by a hairnet, and two male employees had beards not covered. The Manager confirmed each of the items noted above. | 2014-04-01 | ||
| 10159 | 10159 | CAROLINAS HOSP SYS TRANS CARE | 425177 | 121 EAST CEDAR STREET | FLORENCE | SC | 29501 | 2013-03-07 | 520 | F | 375T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility's Quality Assessment and Assurance Program failed to develop and implement appropriate steps to correct identified quality deficiencies concerning ongoing issues related to the dietary department. The findings included: On 3/6/13 at approximately 1:30 PM Registered Nurse (RN) #1, who was identified as the Quality Assessment and Assurance Program (QAA) contact by the Administrator, was asked by the surveyor if there were any ongoing QAA that identified issues related to the kitchen. His/her response was "Yes" and stated he/she would get the information. On 3/6/13 at 4 PM the Manager of Dining and Kitchen Services gave the surveyor a 2012 Quality Improvement Plan for Food & Nutrition Services 4th Quarter Report. The report identified: Indicator, Goal, Results, and Outcome / Plan. On 3/7/13 at 9:41 AM the Administrator gave the surveyor Carolinas Hospital System Food & Nutrition 2012 4th Quarter for "Monitor: Patients will receive meals that are accurate and served at the correct temperature", "Food & Nutrition will maintain a clean and safe environment at all", and "Patients receiving [MEDICATION NAME] nutrition will meet ASPEN Guidelines for appropriateness". The Goal and Results for both 2012 Quality Improvement Plan for Food & Nutrition Services 4th Quarter Report and Carolinas Hospital System Food & Nutrition 2012 4th Quarter were written in percentages and had a completion date of "Ongoing monitor, "Ongoing weekly monitor", or "Ongoing monthly monitor". On 3/7/13 at 9:35 AM RN #1 provided the facility policy on QAA. The QAA for the Transitional Care Unit (TCU) states "The Transitional Care Unit Participates with the Quality Improvement Program of Carolinas Hospital System (CHS). TCU adheres to the policies of CHS in regard to Program Improvement and Quality Assurance and Assessment. RN #1 delivered the Plan for Organizational Improvement for Department Generating… | 2014-04-01 | ||
| 10160 | 10160 | HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST | 425294 | 600 SULPHER SPRINGS ROAD | GREENVILLE | SC | 29611 | 2011-01-13 | 281 | E | EE4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interviews and review of the facility's policy on "Venous Access Devices," the facility failed to assure the nursing staff provided the appropriate interventions for Resident #1's peripherally inserted central catheter (PICC) line (one of two residents sampled with a PICC line.) The facility also failed to assure a newly admitted resident had a written plan of care to meet the needs of that resident. Resident #1's interim care plan did not include his PICC line, his leg wounds or his extensive activities of daily living (ADL) requirements. The findings included: The facility admitted Resident #1 on 2/28/2010 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 3/7/2010 revealed the resident had no short term or long-term memory problems and was independent in decision-making. The MDS documented the resident as having repetitive verbal complaints and was verbally abusive 1-3 days within the assessment period. The MDS also coded the resident as needing extensive assistance with transfers, toileting and bathing. The resident was coded as totally dependent for ambulation on and off the units and was totally dependent for toileting. The resident was coded as frequently incontinent of bowel and bladder. The resident was also coded as have a Stage III ulcer. Review of the Interim Care Plan revealed no problem areas related to his PICC his wound or his need for extensive assistance related to his activities of daily living. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation that the PICC line was flushed every 12 hours. However the resident was receiving antibiotics once daily through the PICC line. Review of the facility's policy on "Venous Access Devices" revealed PICC lines should be flushed a minimum of every 12 hours. The … | 2014-04-01 | ||
| 10161 | 10161 | HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST | 425294 | 600 SULPHER SPRINGS ROAD | GREENVILLE | SC | 29611 | 2011-01-13 | 314 | D | EE4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on observations, interviews, record review and review of the facility's policy on "Treatment Changes," the facility failed to provide the necessary care and services to 2 of 5 sampled residents. Resident #1 did not have the dressing changed per the physician's orders [REDACTED]. Resident #4 also did not receive appropriate wound care to her bilateral lower extremities. The findings included: The facility admitted Resident #1 on 2/28/2010 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 3/7/2010 revealed the resident had no short term or long-term memory problems and was independent in decision making. The MDS documented the resident as having repetitive verbal complaints and was verbally abusive 1-3 days within the assessment period. The MDS also coded the resident as needing extensive assistance with transfers, toileting and bathing. The resident was coded as totally dependent for ambulation on and off the units and was totally dependent for toileting. The resident was coded as frequently incontinent of bowel and bladder. The resident was also coded as have a Stage III ulcer. Review of the Physician order [REDACTED]. To the right leg, clean with wound cleanser, apply Mesalt to wound and then wrap leg with ace bandage, change every day and as needed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the wound care notes revealed a "Skin Alteration" record for the Right leg first dated 2/28/2010. The wound was noted to be 10 cm by 10 cm by 3 cm deep, with a moderate amount of serous drainage and [MEDICAL CONDITION]. No odor was noted. The next note was dated 3/8/2010, the wound was noted to be 2.3 cm by 2.3 cm by 0.1 cm deep, a scant amount of slough was noted, a scant amount of serous drainage was documented and no foul odor. Review of the Physician's Progres… | 2014-04-01 | ||
| 10162 | 10162 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 281 | K | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies for Change of Condition and Laboratory Services, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.20 F-281 at a scope and severity of "K", starting 9/12/10. The facility Nursing staff repeatedly failed to identify a delay in the receipt of laboratory tests and subsequently failed to contact the attending physicians in a timely manner to obtain further medical direction for the assessment, monitoring and treatment of [REDACTED]. Residents # 1, 4, 5, 6, 7, 14, 15, 21,and 29 were 9 of 22 sampled residents reviewed for professional standards related to physician notification of laboratory results who were found to be affected by the deficient practice. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no… | 2014-04-01 | ||
| 10163 | 10163 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 505 | K | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.75 F-505 which was identified at a scope and severity of "K" which began on 9/12/10. The facility failed to assure laboratory test results were returned to the facility in a timely manner and promptly provided to the physician to use for assessment, diagnoses, treatment and initiation of appropriate infection control practice. The systematic failure to provide lab services and notify the physician promptly placed residents at risk for serious harm. The immediate jeopardy was not removed upon exit from the facility. Residents #'s 1,4,5,6,14,15,21 and 29 who were 8 of 22 sampled residents reviewed for Physician notification of lab services were identified with concerns related to physician notification resulting in a delay of treatment. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16… | 2014-04-01 | ||
| 10164 | 10164 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 153 | G | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers rega… | 2014-04-01 | ||
| 10165 | 10165 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 225 | D | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey and complaint investigations, based on review of the facility's investigation into allegations of abuse and/or neglect, the facility failed to thoroughly investigate 2 of the 5 allegations reviewed (Residents #24 and #26). The findings included: Resident #24 with [DIAGNOSES REDACTED].#4. A day shift CNA reported that same day that the resident was found on several mornings with soaked and/or stained linens. The facility obtained statements from the resident's roommate, the accused CNA, and one other CNA assigned to provide care to the resident on one of the "several" 11-7 shifts. The facility failed to investigate to determine the exact dates of the alleged verbal abuse and the exact dates of the alleged neglect of the resident. Their investigation failed to show evidence that other staff members were interviewed concerning the allegations in an effort to identify other potential perpetrators or witnesses to the alleged abuse and neglect. Resident #26 was admitted with [DIAGNOSES REDACTED]. Review of the facility's "Initial 24-Hour Report" dated 12/02/10 and the "Five-Day Follow-Up Report" dated 12/08/10 revealed the alleged perpetrator CNA (Certified Nursing Aide) #13 was not interviewed related to allegation of abuse. Further review of the completed investigative report submitted by the facility revealed that no one at the facility attempted to interview CNA #13. Review of the facility policy on Abuse and Neglect in the "INVESTIGATING" under page 1 of 3 #1 *"Investigation documentation will include, but not be limited to, the following: "Date and time of the alleged occurrence. Patient/resident's full name and room number. Names of the accused and any witnesses. Names of the healthcare center/agency staff who investigated the allegations. Any physical evidence and description of emotional state of patient/resident (s). Details of the alleged incident and injury. Signed statements from pertinent parties." On page 2 … | 2014-04-01 | ||
| 10166 | 10166 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 498 | F | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, review of staff development records, review of the facility policy entitled "NURSING: PERINEAL CARE" (revised 4/07),the facility provided policy for Handwashing and review of the South Carolina Nurse Aide Candidate Handbook (January 2010), the facility failed to ensure that nurse aides were able to demonstrate competency related to implementation of infection control precautions in the provision of incontinent care. Nurse Aides failed to provide appropriate care and services to prevent infections for 13 of 20 residents (Residents #1, #5, #14, #15, #16, #17, #18, #19, #20, #30, #31, #32, #34) during 14 observations for incontinent care. Deficient practice and substandard quality of care was identified (CFR F- 315) during provision of incontinent care by nine of eleven Certified Nursing Assistants (CNAs) on two of three shifts and on three of three nursing units. The findings included: The facility admitted Resident #20 on 11-27-09 with Chronic [MEDICAL CONDITION] and multiple cormorbidities. During observation of incontinent care on 12-13-10 at 5:10 AM, after Certified Nursing Assistants (CNAs) #9 and #10 washed their hands and applied gloves, CNA #10 uncovered the resident from waist to feet and detached his incontinent brief. CNA #9 was unable to locate supplies at the bedside to provide incontinent care. She removed her gloves and left the room to obtain disposable wipes. CNA #9 reentered the room, applied gloves without washing her hands, and proceeded to provide care to the resident who had been incontinent of urine and feces. CNA #9 used one disposable wipe to cleanse both upper inner thighs and groin areas, then the penis, without changing the position of the cloth. When cleansing the penis, the CNA wiped down the shaft, toward the urethra, then cleansed the glans penis. The resident was positioned onto his right side and the CNA proceeded to cleanse the perianal area and but… | 2014-04-01 | ||
| 10167 | 10167 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 441 | F | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the facility policy and procedure related to Infection Control, the facility failed to establish and maintain an effective Infection Control Program. The facility failed to maintain accurate records of infections to determine tracking and trending by resident and organism. (Resident # 30) The facility failed to initiate transmission based precautions in a timely manner for Resident # 21 with a known drug resistant respiratory infection who was located in a multi-bed room; Resident personal equipment was not labelled for individual use; Oxygen equipment was not maintained in a sanitary manner for Resident # 32; and 1 of 3 housekeeping staff was not knowledgeable in housekeeping procedures required to clean resident room who were on isolation. The facility failed to ensure staff used appropriate handwashing during resident care. The facility failed to handle soiled linen in a way which prevented the spread of infection as observed during resident care and observation of the laundry process. The findings included: During Initial Tour of the facility on 12-13-10 at approximately 5:05 AM, this surveyor observed Certified Nursing Assistant (CNA) # 7 coming out of room # 117 with a bag of soiled linen. CNA # 7 went into the soiled utility room, placed the linen in a linen barrel, left the room, and went into the clean linen room. She then proceeded to obtain clean linen and returned to room # 117 to make up the bed. CNA # 7 did not wash her hands after disposing of the soiled linen and before she handled the clean linen. At approximately 6:00 AM, CNA # 7 entered room # 113 in response to a call light, and assisted a resident into the bathroom. On the counter beside the sink in the room were two used urinals with no resident identification. CNA # 7 put each urinal into separate bags and set them in the bathroom, The room was occupied by 2 male residents, but the C… | 2014-04-01 | ||
| 10168 | 10168 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 281 | K | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on chart reviews, interviews, review of The South Carolina State Board of Nursing Advisory Option # 9 B, and review of the facility policies, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident reviewed with a PICC (Peripheral Inserted Central Catheter) line (Resident # 11). The facility nurses failed to clarify with the Physician a discontinued order related to flushing a PICC line. In addition, LPNs (Licensed Practical Nurses) documented that they administered medications through the PICC line with no documentation of advanced training and there was no RN (Registered Nurse) on site when the LPN administered the medications via the PICC line. The facility nurses failed to document consistently that they were flushing the PICC line and failed to note medications used for the flush were taken from a container of expired [MEDICATION NAME] Lock Flushes with a large number of expired [MEDICATION NAME] syringes. In addition the facility nurses failed to recognize signs and symptoms of infection of a surgical wound in a timely manner for Resident # 11, which delayed treatment. The findings included: The facility originally admitted Resident # 11 on [DATE] and after a brief hospital stay readmitted Resident #11 on [DATE] with diagnoses, which included Aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. On [DATE], review of the progress notes revealed that on [DATE] at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On [DATE] at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On [DATE] at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. Th… | 2014-04-01 | ||
| 10169 | 10169 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 425 | J | GN4K12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, the facility failed to ensure that expired medications were not stored with medications readily available for resident use resulting in expired Heparin Lock Flush available for use. Seventy Five of 79-3 millimeter Heparin Lock Flushes, were observed in the medication room with expiration dates prior to the survey, an additional 30 were found 12/13/2010 in the bio-hazard container with an expiration date of 8/1/2010 and 2 used Heparin 3 millimeter syringes were found in the sharps container on 12/13/2010 with expiration dates of 8/1/2010 and 11/1/2010. One of one resident sampled with a Peripherally Inserted Central Catheter (PICC), Resident #11, had a IV flush daily with a Heparin Lock Flush ordered. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on 11/16/2010 with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc Heparin Once a Day at 8PM, start date 11/16/2010". On 12/8/2010, during observation of the facility's medication room, expired supplies were noted to be in the same area as the supplies used for resident care. The medication room contained 14-3 ml. Heparin Lock Flush syringes expired 8/1/2010; 60-3 ml. Heparin Lock Flush expired 11/1/2010 and 1-3 ml. Heparin Lock Flush syringes expired 10/20/2010. The Heparin Lock Flushes were observed to be in an open brown cardboard box, sitting on a cart to the right as you entered the medication room. At 10:45 AM on 12/8/2010, expired items (Heparin Lock Flushes) in the medication room were verified by LPN #1 who then removed them from the medication room. LPN #1 stated all nurses were responsible for ensuring any expired meds were removed from the medication room, but there was no system in place to determine when it sh… | 2014-04-01 | ||
| 10170 | 10170 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 490 | K | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Surveys based on observations, interviews and full and/or limited record reviews, the facility's administrator failed to assure that the facility established and maintained services in the building that met Professional Standards of Practice. The administrator failed to develop a system to ensure that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. The findings included: Cross refers to the following citations: 483.20 (k)(3) Professional Standards F281, with a scope and severity of "K" due to facility failure to clarify orders for Peripherally Inserted Central Catheter (PICC Line) Flushes, Licensed Practical Nurses (LPNs) administering Intravenous (IV) medications via PICC Line and [MEDICATION NAME] Flushes without evidence of advance practice certification. 483.30 (b) Nursing Services F354 with a scope and severity level of "F" due to failure to ensure an (RN) Registered Nurse was working 8 consecutive hours every day and the facility employs a full time Director of Nurses not to be shared with another facility. 483.60 Pharmacy Services F425 with a scope and severity level of "J" due to the facility's failure to ensure that expired medications were not stored with medications available for resident use. 483.75 (l) Clinical Records F514 with a scope and severity of "J" due to inaccurately documenting Medication Administration Records (MARs). Interview with the Nursing Home Administrator was held on 12/8/2010 and again on 12/13/2010. The Nursing Home Administrator confirmed the Director of Nursing was shared with the Senior Community Assisted Living Facility. Time sheets were provided to the surveyors and did reveal there were dates without 8 consecutive hours of RN coverage. The NHA also confirmed that there was not a security feature on the electronic records and if the nurse did not completely log off before … | 2014-04-01 | ||
| 10171 | 10171 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 514 | J | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on full and/or limited record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc [MEDICATION NAME] Once a Day at 8PM, start date [DATE]". On [DATE], review of Resident #11's Medication Record (MAR) revealed 4 dates, [DATE], [DATE], [DATE] and [DATE], which indicated that Licensed Practical Nurses (LPNs) had administered IV antibiotics and IV flushes via a Peripherally Inserted Central Catheter (PICC) Line. During an interview with one of the LPN's that signed off the MAR indicated [REDACTED]'s antibiotic and both saline and [MEDICATION NAME] flushes through the resident's PICC line and that she had advanced training and certification to allow her to administer medications via a PICC Line. On [DATE], during an interview with the facility's Administrator, the Administrator stated that there was a "glitch" in the e-mar (electronic) record keeping system that inserted the wrong nurse's initials onto the MAR. She stated that if the nurse did not log out completely when the shift ended there was no security system that would log them out after a certain time had passed with no activity on the part of the staff member. The Administrator did state the nurses were just not taking the time to log out completely and that when medications were given it would be documented as the wrong nurse having administered the medication. She did state t… | 2014-04-01 | ||
| 10172 | 10172 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 272 | D | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review, interview and review of the facility's policies entitled Smoking, the facility failed to assess for safety in a timely manner Resident #3. Resident #3 was 1 of 1 sampled resident observed while smoking. The findings included: The facility admitted Resident #3 on 9/28/2009 and readmitted her on 11/14/2009 with [DIAGNOSES REDACTED]. On 12/7/2010 at 3:00 PM, during the review of Resident #3's medical chart, the smoking assessments were reviewed. The chart contained a smoking assessment dated [DATE]. The surveyor could locate no other assessments related to smoking. When the surveyors asked Licensed Practical Nurse (LPN) #3 if staff accompanied residents outside to smoke, she stated no. When asked if the residents kept their smoking materials with them, LPN #3 stated that the smoking materials were locked in the Medication Room and that the residents asked for them when they went outside to smoke and returned them to the nurses when they came back inside. At 3:55 PM on 12/7/2010, during an interview with the Director Of Nursing (DON), she verified that there had been no smoking assessment completed on Resident #3 since 10/6/2009. Review of the resident's medical chart revealed that on 8/4/2010 her cognitive status was assessed as 0100 and on 11/2/2010 as 0110 indicating a change in cognitive status. The DON also stated that the facility policy does not require assessments unless the resident has a change in condition. Review on the facility's policy entitled "Smoking" revealed no information related to smoking assessments. | 2014-04-01 | ||
| 10173 | 10173 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 441 | F | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on record reviews, interviews, review of the facility's Infection Control Logs and the facility's policy and procedure entitled Infection Control Program, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility also failed to ensure that expired [MEDICATION NAME] Lock Flushes (3 millimeter (ml), 100 unit (u)/ml (75 of 79), Intravenous (IV) supplies (3 start kits), 1 Biopatch Antimicrobial Dressing, and Vacutainer's (3) were not stored in an area away from resident use items. The findings included: On 12/7/2010, review of the facility's Infection Control Logs revealed that the facility logged resident's who were prescribed antibiotics (Abt.). On 12/8/2010 at 12:45 PM, during an interview, the Director of Nursing (DON) was asked if the facility logged Gastrointestinal illness (vomiting and diarrhea) and Multi Drug Resistant Organisms (MDROs). The DON stated that the facility only logged residents on Abt. (antibiotic) therapy. When asked if the facility tracked and trended to recognize outbreaks and potential educational needs, the DON stated no. Review of the facility's policy and procedures entitled Infection Control Program revealed "I. GOALS: The goals of the Infection Control Program are to: A. Decrease the risk of infection to residents and personal. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection control practices. D. Insure compliance with state and federal regulations relating to infection control. II. Scope of the Infection Control Program. The Infection Control Program is comprehensive in that it address detection, prevention and control of infections among residents..." On 12/8/2010, during observation of the fa… | 2014-04-01 | ||
| 10174 | 10174 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 500 | C | GN4K11 | On the days of the Recertification and Extended Survey, based on record reviews and interviews, the facility failed to provide a contract for emergency dental services for the residents. The findings included: On 12/9/2010, review of the facility's required contracts, the facility failed to provide a contract for emergency dental services. In an interview with the Nursing Home Administrator, the Administrator stated that the facility did not have a dental contract. No signed dated contract for dental services was provided prior to the survey team exiting the facility on 12/13/2010. | 2014-04-01 | ||
| 10175 | 10175 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 156 | C | GN4K11 | On the days of the Recertification and Extended Survey, based on observations and interview, the facility failed to post how to apply for Medicaid and how to apply for refunds from Medicare. In addition, the facility failed to post how to contact the Department of Environmental Control (DHEC). The findings included: On 12/7/2010 and 12/8/2010, observations revealed that the facility failed to post how to apply for Medicaid and how to apply for a refund from Medicare. In addition there was no posting related to how to contact DHEC. Interview with the facility Administrator on 12/8/2010 at approximately 5:00 PM, revealed that she was unaware that the facility did not have the information posted. She confirmed that the information was not posted. The Administrator stated that the information must have been taken down during renovations of the facility and not re-posted. | 2014-04-01 | ||
| 10176 | 10176 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 157 | G | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to notify the attending Physician of the signs and symptoms of an infected surgical wound for one of one resident reviewed with an infected surgical wound. (Resident # 11) The findings included: The facility admitted Resident # 11 on 11/1/2010 with diagnoses, which included aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. Resident #11 was re-admitted [DATE] after a hospital stay. On 12/8/2010, review of the progress notes (nurses notes) revealed that on 11/4/2010 at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On 11/5/2010 at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On 11/6/2010 at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on 11/8/2010 LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On 11/8/2010 an order for [REDACTED]." Interview with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on 11/5/2010 and that the resident's MD (in addition to the resident' attending physician this was also the facility's Medical Director) had not been notified of the change of condition of the wound until 11/8/2010 which resulted in a delay in treatment. On 11/12/2010 the resident was transferred to the hospital at 5:00 AM for Incision and Drainag… | 2014-04-01 | ||
| 10177 | 10177 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 159 | D | GN4K12 | On the days of the Recertification and Extended Survey, based on review of the facility's petty cash fund and interview, the facility failed to adhere to acceptable accounting practices for three of three resident's funds that were reviewed. The findings included: On 12/8/2010, interview with the facility's Business office person # 1, revealed that the facility accepted monies of "less than $50.00 dollars" and kept this in petty cash. Review of the accounting for the funds revealed that Resident # 1's account did not accurately reflect the amount of money that the resident had in petty cash. Review of Resident # 5 accounting of funds, revealed that a receipt from Walgreen ' s for $1.06 however there was no request/authorization for the funds to be spent from the resident/responsible party.Review of Resident A's accounting of funds revealed a receipt for Walgreen ' s for $17.00 dollars and no request/authorization for the funds to be spent from the resident/responsible party.Business office person # 1 confirmed this. | 2014-04-01 | ||
| 10178 | 10178 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 315 | E | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record reviews, observation and review of the facility procedure for suprapubic catheter care, the facility failed to provide appropriate catheter care for two of two residents reviewed for catheter care. During Residents' # 2 and # 4 suprapubic catheter care, the facility staff failed to provide treatment in a manner that would prevent possible infection and failed to follow Physician orders [REDACTED]. The findings included: The facility readmitted Resident # 2 on 2/8/2008 with diagnoses, which included Urinary Tract Infection, [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 12/8/2010 at approximately 3:00 PM, LPN (Licensed Practical Nurse) # 2 was observed to perform suprapubic catheter care on resident # 2. The nurse failed to wash her hands prior to donning gloves and was observed to use her gloved hand to turn on the faucet and run water into a basin. She placed the basin on the resident's overbed table, returned to the bathroom and using her right gloved hand dispensed soap onto a hand towel touching the trigger of the wall soap dispenser. LPN # 2 draped the resident with a towel. There was no dressing around the insertion site and the left side of the insertion site was observed to have a small amount of red tinged drainage. Using the hand towel, LPN # 2 cleaned around the catheter insertion site with a back and forth motion without changing position of the hand towel. Next LPN # 2 cleansed down the catheter tubing. LPN # 2 placed the hand towel back into the hand basin filled with water and was observed to use the same towel and again used a back and forth motion around the insertion site without changing position of the hand towel and then wiped down the catheter tubing. Bright red tinged drainage was observed on the right side of the catheter site. LPN # 2 returned the hand towel to the basin and picked up the towel she had used to drape the resident and using the sid… | 2014-04-01 | ||
| 10179 | 10179 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 354 | F | GN4K12 | On the days of the Recertification and Extended Survey, based on observation and interviews, the facility failed to have a RN (Registered Nurse) on duty for eight consecutive hours daily. In addition, the facility failed to employ a full time DON (Director of Nurses). The findings included: Review of the facility staffing revealed that on the following days that the facility failed to have a RN on duty for eight consecutive hours daily:10/23/ 1/6/ 1/13/ 1/20/ 2/4/2010 Interview with the facility administrator and the DON on 12/8/10 confirmed that the facility did not have the correct RN coverage on the above dates. In addition, the Administrator stated the DON did not work full time for the skilled area; that she also had duties for the Assisted Living area. | 2014-04-01 | ||
| 10180 | 10180 | NHC HEALTHCARE - MAULDIN | 425359 | 850 E. BUTLER RD. | GREENVILLE | SC | 29607 | 2010-12-21 | 332 | D | 7CTK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews, the Drug Facts and Comparisons book (updated monthly) and the Drug Information Handbook for Nursing, 8 th Edition, 2007, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The medication error rate was 6.5 percent. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 12/20/10 at 4:29 PM, during observation of medication pass, Licensed Practical Nurse (LPN) #3 was observed to instill one drop of [MEDICATION NAME] Ophthalmic Suspension into each eye of Resident A without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug." During an interview on 12/20/10 at 4:48 PM, LPN #3 confirmed she did not shake the [MEDICATION NAME] Ophthalmic Suspension before instillation into the resident's eyes and further stated that she knew that [MEDICATION NAME] should be shaken. Error #2: On 12/20/10 at 4:53 PM, during observation of medication pass, LPN #4 was observed to prepare and administer 1 [MEDICATION NAME] 150 milligram (mg) tablet and one other medication to Resident #23. Review of the current physician's orders [REDACTED]. [MEDICATION NAME] 150 MG TABLET TAKE 1 THREE TIMES DAILY - REC. (record) PULSE PER POLICY-" LPN #4 was not observed to take the resident's pulse prior to administering the medication. Review of the facility's policy revealed that antiarrhythmic drugs (which included [MEDICATION NAME]) required a daily pulse. During an interview on 12/20/10 at 6:23 PM, LPN # 4 confirmed she had not taken the resident pulse and that there was no place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the pharmac… | 2014-04-01 | ||
| 10181 | 10181 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 441 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interviews, the facility staff failed to demonstrate appropriate knowledge related to infection control issues. The findings included: On 8/11/10 at approximately 9:30 AM during an interview with LPN # 1 when questioned what he/she would tell visitor's prior to entering a resident's room who had an order for [REDACTED]. On 8/11/10 at approximately 9:45 AM interview with Housekeeper # 1, who was responsible for cleaning a room with a "Stop See the Nurse Prior to Entering." sign was questioned what the sign meant. Housekeeper # 1 was unable to tell the surveyor why the sign was posted. When questioned if he/she would utilize any special cleaning procedures for a resident who was on contact isolation for Clostridium Difficile, he/she failed to identify to use any chemical to clean the room. On 8/11/10 at approximately 10:15 AM RN # 4 was questioned what he/she would tell a visitor prior to entering a resident's room who was on contact precautions. He/She stated that he/she was unsure what to tell a visitor. On 8/11/10 at approximately 11:00 AM, Housekeeper # 2 was questioned if he/she would use any special procedure to clean a resident's room who was on contact isolation for Clostridium Difficile, and he/she stated no. When questioned if he/she had been trained on cleaning procedures for rooms that had resident's with infection control precautions, he/she said no. | 2014-04-01 | ||
| 10182 | 10182 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 425 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 2 of 4 medication rooms. The finding included: On 8/9/10 at approximately 11:15AM, inspection of the 1 South Medication Room revealed one orange colored Emergency Box sealed with a red integrity seal and bearing an outside label which read Meclizine expired 7-27-10. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg (milligram)/ml (milliliter), 50 ml. by Hospira, Lot 68-435-DK, expired 1 [DATE] (August 1, 2010). -One Extended Phenytoin Sodium 100mg capsule lot 39 expired 8-5-10 (packaged by NCS Healthcare of SC) -Two Ciprofloxacin 500mg tablets lot BEM51B LC expired 7-2-10 (packaged by NCS Healthcare of SC) -Five Meclizine HCl 25mg tablets lot 601 EH expired 7-27-10 (packaged by NCS Healthcare of SC) These findings were verified by RN (Registered Nurse) # 1 (Floor Manager) on 8/9/10 at approximately 11:25AM who stated that the Consultant Pharmacist is supposed to check for out- of-date medications during monthly visits and was unsure whether the nurse was also responsible for checking on an ongoing basis. RN # 1 a lso confirmed that this emergency box was used to supply medications to all residents on the first floor. On 8/9/10 at approximately 1:40PM, inspection of the 2 North Medication Room revealed one orange colored Emergency Box sealed with a green integrity seal. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg/ml, 50 ml. by Hospira, Lot 68-434-DK, expired 1 [DATE] (August 1, 2010) This finding was verified by LPN (Licensed Practical Nurse) # 1 on 8/9/10 at approximately 1:50PM. LPN # 1 stated that the box had been delivered on 8/6/10 by the Pharmacy and that the green integrity seal indicated that it had not been opened since delivery. This findi… | 2014-04-01 | ||
| 10183 | 10183 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 279 | D | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop, review and revise the resident's comprehensive plan of care for 2 of 9 resident care plans reviewed. No Care Plan for Resident #7 was developed for [MEDICATION NAME] Therapy and Resident #9 had no Care Plan related to allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. On 9/7/2010 at 3:20 PM, review of the medical chart for Resident #9 revealed that the resident had multiple medication allergies [REDACTED]. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OPsite, *No sleeping Pills Per POA (Power Of Attorney). Further review indicated that there was no Care Plan in the record related to Resident #9's numerous allergies [REDACTED].#9 had no Care Plan for allergies [REDACTED]. The facility admitted Resident # 7 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 9/7/10 revealed this resident to be receiving [MEDICATION NAME] 5 mg(milligrams) every night. Lab studies were done per physician's orders [REDACTED]. Continued review revealed no care plan had been developed related to anticoagulant therapy and the [MEDICATION NAME] usage since the resident was admitted . In an interview with the DON (Director of Nursing) on 9/8/10, s/he confirmed there was no care plan related to the [MEDICATION NAME]… | 2014-04-01 | ||
| 10184 | 10184 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 281 | G | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews and review of the facility's protocol for Care Of Skin Abrasions, the facility failed to provide services for the residents which met the professional standards of quality for 1 of 9 residents sampled for professional standards and random observations during medication pass. Resident #9 had documented allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 9/7/2010 at 3:20 PM revealed that the resident had multiple allergy inconsistencies documented. The allergy sticker on the inside of the chart listed [MEDICATION NAME], Sulfa, [MEDICATION NAME], Amox. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OpSite, *No sleeping Pills Per POA (Power Of Attorney). Review of the Nurses' Notes dated 8/2/2010 at 0630 (6:30 AM), indicated that the resident had rubbed a scab off of the right side of her/his face. The nurse cleaned the area and applied "TAO (Triple Antibiotic Ointment) and a band-aid". At 5:00 PM, the Nurses' Notes revealed that the area on the right side of the resident's face was "red & (and) irritated. Res. (resident) states is painful to touch. On MD (physician) book for eval. (evaluation)." No other entries related to the resident's face were noted until 8/10/2010 at 4:40… | 2014-04-01 | ||
| 10185 | 10185 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 371 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Four of 4 ovens were observed to have dried, baked on spills on the interior walls, racks and floors of the ovens which extended to the exterior surfaces of the oven doors. The resident refrigerators on 2 of 3 units contained 16 [MEDICATION NAME] Extra nutritional supplements which had expired. The findings included: On 9/7/2010, during initial tour of the facility's kitchen, 4 ovens were observed to have a build up of food spills which were baked onto the oven doors and interiors. On 9/8/2010 at 8:40 AM, during an additional tour of the kitchen the ovens remained unchanged. On 8:45 AM, Dietary Staff worker #1 verified the ovens with the build up. At 9:20 AM, the Dietary Manager stated that the ovens were on a cleaning schedule but there was not a check of to ensure the staff had completed the task. A cleaning check off was initiated and provided on 9/8/10. During initial observation of the resident refrigerator on the Orchard View unit, 13- 8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010 were noted. The location of the supplements and expiration date was verified by the Director Of Nursing. At 10:35 AM, Licensed Practical Nurse (LPN) #1 stated that the unit had 1 resident receiving the [MEDICATION NAME]. The resident refrigerator on the Overlook Point Unit contained 3-8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010. The location of the supplements and expiration date was verified by Certified Nursing Assistant (CNA) #3. | 2014-04-01 | ||
| 10186 | 10186 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 492 | E | 9VMS11 | On the days of the survey, based on review of personnel files, the facility failed to verify 2 of 3 LPN's (Licensed Practical Nurses) license were in good standing with the State Board of Nursing prior to hiring. The facility also failed to verify the criminal back ground for 1 of 3 LPNs prior to the hire date.The findings included:On 9/7/10 review of LPN #7's personnel file revealed that LPN # 7 started work on 6/16/10, however the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 6/30/10. Review of LPN #8's personnel file revealed that LPN #8 started work on 7/7/10, the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 7/20/10. The facility also failed to complete a criminal background check for LPN #8 until 7/20/10. LPN #9's hire date was 7/7/10 and the facility completed the license verification on 7/20/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the nurses. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10187 | 10187 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 496 | E | 9VMS11 | On the days of the survey, based on employee personnel record reviews and interviews, the facility failed to verify certification checks and/or criminal background checks prior to beginning work for 3 of 2 Certified Nursing Assistant's reviewed for certification verification and criminal background checks.The findings included:On 9/7/10 review of employee personnel records revealed that the facility failed to verify certification for 2 of 2 CNAs (Certified Nursing Assistants) prior to beginning work. On 9/7/10, review of the CNA personnel records revealed:CNA # 1 began work on 6/9/10 with verification completed 8/11/10.CNA # 2 began work on 6/16/10 with her/his criminal background check completed on 6/17/10 and verification completed 7/31/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the CNA's. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10188 | 10188 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 160 | B | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds for conveyance upon death, the facility failed to convey one fund within 30 days of death, and failed to have proper authorization to convey 2 other resident funds. The findings included: An interview with the Business Office Manager on [DATE] related to conveyance of funds upon death revealed 3 of 4 accounts reviewed were refunded improperly. Account of Resident A, who expired on [DATE], was refunded by check written on [DATE]. The manager explained that corporate had recently found several accounts that had not been refunded, and she made out the check this day. Resident B had expired on [DATE] and a check had been made out to Colonial Trust on [DATE]. No legal authorization had been obtained to make the check out to this entity. Resident C expired on [DATE], and a check was made out on [DATE] to a son who had not been appointed as an administrator of the estate. | 2014-04-01 | ||
| 10189 | 10189 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 167 | C | 9VMS11 | On the days of the survey, based on observation and interview, the facility failed to post for resident review the Certification Survey for 8/20/09. The findings included: During a random observation on 9/7/10, the facility survey book, located upstairs in the skilled unit, was reviewed and found it contained last year's Licensure Survey, a Complaint Survey, and a Certification Survey dated 2008. The Certification Survey results for 8/20/09 were not included. The Director of Nursing (DON) reviewed the book and confirmed the survey was not included. The DON reviewed the survey book posted downstairs at the entrance and confirmed that book also did not have the 2009 Certification Survey included. | 2014-04-01 | ||
| 10190 | 10190 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 441 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of facility Infection Control Policies, Logs, and interviews, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection related to cleaning/non cleaning of glucometers, not making documented compliance rounds of all departments, and not keeping accurate infection control logs for trending and tracking of infections. There were also expired supplies in 2 of 3 medication rooms. The findings included: Review of the monthly infection control logs on [DATE] and [DATE] revealed list of x-rays done each month and pharmacy printouts for residents on antibiotics for each month with listings of residents, tests done, organisms identified, antibiotics started. However, these listings were not in order by date. When the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were interviewed regarding their infection control program, they stated the ADON filled out the log weekly or bi-weekly. They received the printouts from X-Rays and Pharmacy the next month so those were added to the logs then. The logs were not current. When asked how they did their tracking or trending for infections, they stated they had weekly meetings where infections were discussed. If they saw more infections were occurring, they would check to see which unit. No line listing of MDRO's ( Multi Drug Resistant Organisms) in the facility were being kept. The Admission's Coordinator would have to call someone in Nursing before placing a new resident. The ADON did not do compliance rounds to other departments for infection control. She stated she supposed the department heads did their own rounds. She did not receive any written reports for these. She did not do compliance rounds in nursing, but did competency checks on staff yearly. During observation of medication pass on [DATE] at 3:30PM, Licensed Practical Nurse #6 was observed to use a multi-residen… | 2014-04-01 | ||
| 10191 | 10191 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 309 | D | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to follow a physician's order to monitor Resident # 14's blood pressure before administering a medication. Resident #14 was one of four sampled resident's receiving medications with physician ordered parameters for administration. The findings included: Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. On 9/8/10, a review of the closed medical record revealed a physician's order for "[MEDICATION NAME] 60 milligrams, hold if pulse is less than 40" and notify the physician. A review of the July and August 2010 Medication Administration Records revealed there was no documentation that the resident's pulse was obtained/documented prior to the medication administration given daily at 6AM, 12P, 6P, or 12AM. The findings were verified and not disputed when shared with the Director of Nursing on 7/8/10 at 10:30 AM. | 2014-04-01 | ||
| 10192 | 10192 | THE LAKES AT LITCHFIELD SNF | 425380 | 120 LAKES AT LITCHFIELD DRIVE | PAWLEYS ISLAND | SC | 29585 | 2011-01-24 | 225 | D | T04211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of the facility's investigative materials related to 2 of 2 resident falls with fractures, the facility failed to report timely and failed to thoroughly investigate a fall with fracture (Resident #1) and failed to report a fracture of unknown origin (Resident #2). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Because the resident had poor safety awareness and made attempts to get out of bed, a tab alarm, when in the chair and when in the bed, was ordered at 6 AM on 12/9/10. At 6:30 AM on 12/9/10, the resident was found on the floor of his room. The alarm did not sound because the resident held it in his hand. The previous order for the tab alarm was discontinued and a pressure pad alarm was ordered for the bed and chair. The resident fell again on 12/11/10 at 9:35 AM. According to the Nurse's Note, the resident was found sitting on his buttocks in the dining room. His urinary catheter was intact. No immediate signs of injury were noted. Later that morning, at 11:30 AM, the resident complained of left leg pain and he was sent to the hospital where a fractured femur was diagnosed . The facility reported this incident to the State survey and certification agency on 12/13/10, which exceeded the 24 hour limit for initial reports. During an interview with the Administrator and Director of Nurses on 1/24/10 at 1:10 PM, they stated they thought the facility had 24 "business hours" to report the incident. The resident fell on a Saturday and the initial facility report was made on Monday. Review of the facility's investigative materials revealed documentation on the fall report stating: "Aide was returning tray to kitchen when resident attempted to stand up & fell . Alarm did not sound." The Certified Nursing Assistant's (CNA's) statement said: "Resident was in the dinning (sic) room talk I went to Clean up and take his plate to the kitchen he tried to get up and fell . Alarm didn't go off. When… | 2014-04-01 | ||
| 10193 | 10193 | THE LAKES AT LITCHFIELD SNF | 425380 | 120 LAKES AT LITCHFIELD DRIVE | PAWLEYS ISLAND | SC | 29585 | 2011-01-24 | 323 | D | T04211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record reviews and interviews, the facility failed to ensure that personal safety alarms were used as ordered for 1 of 1 resident who fell and sustained a fractured femur (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Because the resident had poor safety awareness and made attempts to get out of bed, a tab alarm when in the chair and a pressure pad alarm for the bed was ordered at 6 AM on 12/9/10. At 6:30 AM on 12/9/10, the resident was found on the floor of his room. The alarm did not sound because the resident held it in his hand. The previous order for the tab alarm was discontinued and a pressure pad alarm was ordered for the bed and chair. The fall report stated the pressure pad alarm "was applied." The Nurse's Notes entry on 12/9/10 at 2125 (9:25 PM) stated "pressure pad alarm in place." Review of the 11-7 Nurse's Notes for 12/10-11/10 showed the resident made numerous attempts to get out of bed unassisted. The resident fell again on 12/11/10 at 9:35 AM. According to the Nurse's Note, the resident was found sitting on his buttocks in the dining room. His urinary catheter was intact. No immediate signs of injury were noted. Later that morning, at 11:30 AM, the resident complained of left leg pain and he was sent to the hospital where a fractured femur was diagnosed . Review of the facility's investigative materials related to the fall with fracture revealed the safety alarm did not sound. The investigation also revealed the resident did not have the pressure pad alarm in place, but instead the tab alarm was in place that day. Their investigation did not show if the alarm was on and functioning, or why it did not sound on 12/11/10. Review of the Treatment Record showed nurses' initials for "Pressure pad alarm WIB/WIC (when in bed/when in chair) d/t (due to) poor safety awareness" for 3-11 and 11-7 on 12/9 and 12/10/10, and for 7-3 on 12/11/10. The initials indicated … | 2014-04-01 | ||
| 10194 | 10194 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 441 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to sanitize residents' personal laundry. The findings included: During observation on 9/14/10 at approximately 1:36 PM, Laundry Aid #1 loaded multiple residents' personal laundry into the washer and set the cleaning solution pump on "F1." The sign posted on the wall stated F1 solution was without bleach. During an interview at that time, the laundry aid stated she always used setting 1 for residents' personal clothes so they wouldn't be damaged. At 1:46 PM, during an interview, the Area Mechanic stated the water in the washer was between 115 and 120 degrees. He further stated the water used to be at 180 degrees but, after changing chemicals, they had been told the water temperature didn't need to be that high. At approximately 3:08 PM on 9/14/10, the Director of Environmental Services confirmed that the F1 setting did not include bleach and stated the (solution) pump should have been set on the F2 setting which added bleach after five minutes. Review of the detergent container did not reveal that the detergent contained any sanitizer. The Director of Environmental Services did not provide any additional information that the detergent had any bateriocidal properties. | 2014-03-01 | ||
| 10195 | 10195 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 333 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that one of 20 residents reviewed for medication assessment was free of significant medication errors. Potassium was not administered as ordered to Resident #6 for a period of 5 days. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was "nil" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed 7-19-10 physician's orders [REDACTED]. Review of the 7-19-10 Basic Metabolic Profile revealed the following results: Sodium = 130 LOW (reference 135-145 mmol/L); Potassium = 4.9 (reference 3.6-5.0 mmol/L); Chloride = 95 LOW (reference 101-111 mmol/L); Blood Urea Nitrogen = 52 HIGH (reference 6-20 mg/dl); Creatinine = 1.8 HIGH (reference 0.5-1.2 mg/dl). Review of the 7-10 Documentation Record (Medication Administration Record/MAR) revealed that the medication was held as ordered and that the [MEDICATION NAME] was resumed on 7-27-10. The Potassium (20 milliEquivalents daily) was not initialed on the MAR indicated [REDACTED]. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses verified that the medication had not been initialed as given for the five day period as noted. She stated she had been unaware of the omissions, no medication error report had been completed, and the physician had not been notified. She reviewed the record and verified that no recent Potassium level had been drawn. | 2014-03-01 | ||
| 10196 | 10196 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 315 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled "Skills Checklist for Suprapubic Catheter Care", the facility failed to ensure appropriate treatment and services for residents with catheters. The Certified Nursing Assistant (CNA) failed to properly anchor the suprapubic catheter tubing during catheter care for Resident #2, one of three residents observed with catheter care. Also, the facility failed to assess oral intake and urinary output as indicated by residents' medical condition for one of two sampled residents reviewed with an indwelling Foley catheter and Care Plan for intake and output monitoring. Resident #6, with a history of fluid imbalance and [MEDICAL CONDITION], had incomplete intake and output documentation. The findings included: The facility admitted Resident #2 on 10/22/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 9/14/10 at 12:23 PM revealed CNA(Certified Nursing Assistant) #2 cleaning, rinsing, and drying the catheter tubing. She held the tubing between her index finger and thumb, approximately 4 inches from the insertion site, and anchored it to the resident's thigh while wiping down the tubing. The CNA cleansed from the insertion site distally toward where she held the catheter, causing undo tension on the catheter tubing. During an interview on 9/15/10 at 11:25 AM, CNA #2 verified she had anchored the catheter tubing at the resident's thigh instead of at the insertion site while performing catheter care. She stated she thought she was supposed to anchor the tubing to the thigh. Review of the policy entitled "Skills Checklist for Suprapubic Catheter Care" on 9/15/10 revealed "...6. Apply soap to one wet cloth, 7. Hold tubing (Without pulling) in other hand, 8. Wash around one side of tubing with soapy cloth-, 9. Using a different, clean part of cloth- wash around the other side of the Tubing, 10. Hold the tubing closest… | 2014-03-01 | ||
| 10197 | 10197 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 332 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.5 %. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 9/13/10 at 8:36 PM, during observation of medication pass, Registered Nurse (RN) #5 was observed to administer two Klor-Con 10 (Potassium Chloride Extended Release) tablets and 7 other medications to Resident #10. During an interview on 9/13/10 at 8:48 PM, RN #5 revealed that supper trays arrived on the unit at about 6 PM and that Resident #10 had eaten in his room (approximately 2 and one-half hours before the potassium was administered). The Drug Facts and Comparisons book, page 49 (Potassium Replacement Products), states (under "Patient Information"): "May cause GI (gastro-intestinal) upset; take after meals or with food and with a full glass of water." Error #2: On 9/13/10 at 9 PM, during observation of medication pass, RN #2 was observed to administer one drop of [MEDICATION NAME] Ophthalmic Solution and one drop of [MEDICATION NAME] Ophthalmic Solution to the right eye of Resident A with one minute and 56 seconds between the two drops. RN #2 then administered one drop of the same two eye drops to the resident's left eye with 2 minutes and 4 seconds between the 2 drops. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Because of rapid lacrimal drainage and limited eye capacity, if multiple drop therapy is indicated, the best interval between drops is 5 minutes. This ensures that the first drop is not flushed away by the second or that the second drop is not diluted by the first.". Error #3: On 9/14/10 at 7:47 AM, during observation of medication pass, RN #1 was observed to instill one drop of [MEDICATION … | 2014-03-01 | ||
| 10198 | 10198 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 225 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property" dated 2/09, the facility failed to complete a thorough investigation for one of one reportable incidents reviewed for misappropriation of funds. The findings included: One of three reportable incidents reviewed on 9/15/10 revealed that a resident reported $44.00 missing from his room on 9/7/10. According to the DHEC (Department of Health and Environmental Control) Five-Day Follow-Up Report dated 9/13/10, "He had noticed this the week prior to the report". Under "Witnesses and other Staff on duty at time of/or prior to Reportable Incident:", there was nothing written. According to the report, the missing money had been reported by the facility to the Union County Sheriff's Office on 9/8/10. The "Summary Report of Facility Investigation:" stated "(Resident) keeps various items in the basket where he reported the money had been stored. (Numerous pieces of mail, straws, playing cards, and various other items). He has been reminded again to lock up any large amounts of money." Attached to the Five-Day Follow-Up Report was a letter dated May 4, 2010 from the Administrator addressed to residents and their families reminding them that the facility could store valuables and that residents are encouraged to not keep any items of personal or monetary value in their room. The letter went on to state that "The facility will take every precaution to protect belongings but cannot be accountable for valuables left in resident rooms". There were no resident or staff statements attached or evidence of a thorough investigation being completed. During an interview on 9/15/10 at approximately 12:30 PM, the Social Services Director (SSD) stated the resident had a history of [REDACTED]. After reviewing the Five-Day Follow-… | 2014-03-01 | ||
| 10199 | 10199 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 323 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, "DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : "RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness". SAFETY STATEMENTS on the MSDS read: "Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges." HANDLING AND STORAGE SECTIONS of the MSDS stated, "STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). K… | 2014-03-01 | ||
| 10200 | 10200 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 309 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to follow physician's orders for application of Knee High TED (antiembolism stockings) Hose for Resident # 11, 1 of 4 residents reviewed with orders for TED Hose. The facility also failed to include provision of Services from a Chaplain and Social Services in the care plan and no documentation of visits from these disciplines were found in the record for Resident #18, 1 of 2 resident's reviewed receiving Hospice Services . The findings included: The facility admitted Resident #11 on 4/26/04 with [DIAGNOSES REDACTED]. Record Review on 9/14/10 at approximately 6:15 PM revealed a Physician's Order for "Knee high TED hose on in the morning before getting out of bed & (and) remove at bedtime ([MEDICAL CONDITION])" with a start date of 9/16/08. Observation of the resident at 6:25 PM on 9/14/10 revealed the resident was not wearing TED Hose. During an interview on 9/15/10 at 1:15 PM, the resident stated she had never had any stockings and that she did have swelling in her feet "sometimes." Review of the resident's Minimal Data Set revealed the resident was coded as not having any short or long term memory problems. The resident was named on the list provided by the facility of Interviewable Residents and she was a member of the Resident Council. Record Review on 9/15/10 at approximately 1:30 PM revealed that the TED Hose had been signed off daily for August and September, including being signed off for being applied the morning of 9/15/10. During an interview on 9/15/10 at approximately 2:15 PM, Registered Nurse (RN) #4 stated she had just received a new pair of TED Hose for the resident the previous week. Upon observation of the resident, RN #4 confirmed the resident was not wearing TED Hose. RN #4 was unable to locate any TED Hose in the resident's drawers. When informed of the resident's statement that she had never had any stockings, RN #4 stated:… | 2014-03-01 | ||
| 10201 | 10201 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 322 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility's policies entitled "Gastrostomy Tube Check List" and "Procedure for Cleaning 60 cc (cubic centimeters) Syringes Used for Resident Feeding", the facility failed to utilize universal precautions and clean technique when flushing the Gastrostomy (G-) Tube and when cleaning and storing the piston syringes and gravity set for 2 of 3 residents observed for Gastrostomy Tube flushes. The findings included: The facility admitted Resident #5 on 7/17/09 with [DIAGNOSES REDACTED]. On 9/14/10 at approximately 12:33 PM, Licensed Practical Nurse (LPN) #6 was observed by two surveyors providing a Gastrostomy Tube flush before and after medication administration without washing her hands prior to initiating the procedure. LPN #6 opened the Medication cart, retrieved a bottle of liquid Tylenol from the drawer and poured 20 milliliters (ml) of Tylenol into a medication cup. LPN #6 proceeded to the resident's room, knocked, entered the room and filled the 2 empty medicine cups with 30 ml of water from the sink and placed all 3 medicine cups on the over-bed table. She then closed the door, opened a plastic bag and placed it on the foot of the bed and donned a pair of non-sterile gloves. LPN #6 proceeded to check for and replace residual, checked for placement of the [DEVICE], and administered the 30 ml flush, the medication and ended with another 30 ml flush. Upon completion of the procedure, the piston syringe was rinsed and placed wet, back into the bag. Review of the "Gastrostomy Tube Check List" provided by the facility on 9-14-10 revealed "2. Placement check: Check placement before flushes,...Gather supplies..., Explain procedure to Resident, Provide Privacy, Wash Hands, (apply) Non-sterile gloves, ..." The facility admitted Resident #3 on 4-8-01 with [DIAGNOSES REDACTED]. Prior to observation of a Gastrostomy (G-) feeding and flush on 9-14-10 beginning at 9:55 AM, two C… | 2014-03-01 | ||
| 10202 | 10202 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 328 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to follow the Physician's Orders for the administration of oxygen for 1 of 4 sampled residents reviewed with oxygen. Resident # 18 oxygen rate was observed above the stated physician's order. The findings included: The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of the record on 9/15/10 at approximately 11:00 AM revealed a Physician's order for O2 (oxygen) at 2 liter per minute (lpm) via NC (nasal cannula.) Review of the Hospice Nursing Visit Note revealed the Hospice nurse had documented the oxygen at 3 lpm via NC on 9/15/10, 9/8/10 and on 8/23/10. Review of the Documentation Record (MAR) revealed facility nursing staff was signing off the O2 at 2 lpm via NC each shift including the days of the survey. Observation on 9/15/10 at approximately 11:30 revealed the oxygen was flowing at approximately 3 1/2 lpm via NC. At approximately 1:00 PM on 9/15/10, Registered Nurse (RN) # 4, verified the oxygen was flowing at 3 1/2 lpm via NC. Upon questioning, she stated "I'd have to check the MAR (Documentation Record) but I'm pretty sure it's supposed to be at 2 (lpm)." RN #4 also reviewed the record and confirmed the Physician's Orders and the MAR indicated and could not locate any new order to increase the flow rate. During an interview on 9/15/10 at 2:28 PM, the Hospice Nurse stated the oxygen was supposed to be at 2 lpm and had been since admission to Hospice. She stated she thought the oxygen flow rate had inadvertently been changed on 9/15/10 when the Certified Nursing Assistant had reached to turn the oxygen back on after the resident's AM care had been completed. She stated the 3 lpm documented on the Nursing Visit Note for 9/15/10 had been a documentation error only. The Hospice Nurse later changed the documentation on the 9/8/10 Nursing Visit Not… | 2014-03-01 | ||
| 10203 | 10203 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 468 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to equip multiples areas in the corridors with handrails. The findings included: On 9/15/10 at approximately 1:55 PM, multiple areas leading into or on corridors were observed without handrails affixed to the walls. Areas included, but were not limited to: -an area approximately 3 1/2 feet at the entrance to Rocky Road Hall on the left and right sides of the hall -an area approximately 3 1/2 feet at the entrance to Rainbow Row Hall on the right side of the hall -approximately 5 feet across from the Unit I Nurses Station -a section approximately 8 feet long in a corridor behind the Unit I Nurses Station -the entire length of the corridor connecting Unit I and Unit II on both sides of the hallway -two 5 foot sections and two 3 1/2 foot sections on Unit II at the Nurses Station and several other areas leading into the 3 halls from the nurses station. During an interview on 9/14/10 at approximately 4:15 PM, the Maintenance Director verified multiple areas were without handrails and stated that the corridor between Units I and II had never had handrails as far as he knew. He also stated that the area behind the Unit I Nurses Station "looks like there used to be one there." | 2014-03-01 | ||
| 10204 | 10204 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 323 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review, interviews, review of the facility's policy on Falls, and review of the facility's inservices, the facility failed to assure each resident was free of accidents as was possible for 1 of 6 sampled residents. Resident #1 sustained 3 falls in 3 days without new interventions implemented. Resident #1 fell on ,[DATE], 7/30 (sustained injuries to the face and mouth) and on 8/1/2010, no interventions were implemented until 8/2/2010. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as needing extensive 1 person assistance with transfers and bed mobility and completely dependent for locomotion on and off the unit. Resident #1 was also coded as dependent for eating, dressing, hygiene, and bathing with no behaviors coded as occurring during the assessment period. The resident was coded as receiving Hospice services. Resident #1 was not coded as having any accidents within 180 days. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8… | 2014-03-01 | ||
| 10205 | 10205 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 280 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews, the facility failed to assure 1 of 6 resident's care plans were reviewed and revised appropriately. Resident #1's care plan was not reviewed and revised with each fall. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8/2/2010 at 11 AM, the nurses' note indicated an order was obtained for a bed alarm and 1/2 lap tray. Review of the care plan revealed a risk for injury (falls) related to weakness, history of [MEDICAL CONDITION], dementia and [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "observe frequently, call light within reach..., provide assistive devices for mobility, provide assistance with mobility, review circumstances of how falls occur to try to eliminate further falls, keep floor/pathway free of debris, notify MD/hospice PRN (as needed)." The care plan was updated on 7/29/2010 with a handwritten note to "observe res(ident) frequently when up." The care plan was not updated with the 7/30/2010 fall or the 8/1/2010 fall. On 8/2/2010 the bed alarm was written on the care plan, however the lap tra… | 2014-03-01 | ||
| 10206 | 10206 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 323 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to provide residents and staff with adequate supervision to ensure it's system for safe transfer of residents was followed by Hospice and facility staff members for 1 of 1 resident reviewed who sustained injury from an inappropriate transfer (Resident #1). Resident #1 was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to [DATE] because of acute renal failure and congestive heart failure exacerbation. Several medications were discontinued on his return to the facility including the Prednisone the resident had taken for years. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to osteoporosis, risk for falls, risk for complications due to CVA with left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as n… | 2014-03-01 | ||
| 10207 | 10207 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 282 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews the facility failed to ensure that care plans were followed for Resident #1, 1 of 3 sampled residents care planned for a mechanical lift with transfers, was transferred from bed to chair on [DATE] by manual lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to [MEDICAL CONDITION], risk for falls, risk for complications due [MEDICAL CONDITION] left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical … | 2014-03-01 | ||
| 10208 | 10208 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 225 | D | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Resident #1, 1 of 1 sampled resident that sustained an injury during a transfer, was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift, as care planned, by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the ax… | 2014-03-01 | ||
| 10209 | 10209 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2010-11-10 | 280 | D | 0LRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection, based on observations, interviews and record reviews, the facility failed to ensure that Resident #4's care planned was review and revised regarding one-to-one supervision by the staff (1 of 4 sampled reviewed with behaviors). The findings included: The facility admitted Resident #4 on 10/23/09 with [DIAGNOSES REDACTED]. Review the of Nurse's Progress Notes dated 10/03/10 at 1250 documented at 1145 the staff was paged to the facility's canteen and that Resident #4 was in the canteen area and he threw a chair at a snack machine, hit a visiting family member of another resident and slammed a nurse's finger in a cabinet. The Nurse's Note further indicated that once the resident calmed down he requested to call law enforcement. At 1245 physician's orders [REDACTED].#4 returned to the facility from the hospital; at 1930 Resident #4 was noted running his wheelchair into people and things. The resident later calmed down and went to bed. A Nurse's Note dated 10/04/10 at 2330 indicated the staff was at the bedside with no behaviors noted. A Nurse's Note dated 10/05/10 at 0830 indicated the staff was at the bedside with no behaviors noted; at 2145 the resident became agitated and talked about hitting the vending machine on 10/03/10. Nurse's Note date 10/06/10 indicated that a staff member was at the bedside and in attendance when family and friends visited the resident. A Nurse's Note dated 10/07/10 at 1340 indicated Resident #4 was in the facility lobby with a staff member when he knocked over a table in the front lobby and tried to hit a staff member with a chair. The resident was return to the unit and given 5 mg (milligrams) of [MEDICATION NAME] IM for combativeness. An observation on 11/03/10 at 11:10 AM, 1:30 PM and 2:10 PM revealed staff seated in the room with the resident. There was nothing in the chart to indicate why a staff was seated in the room with the resident. There was no care plan to indicate … | 2014-03-01 | ||
| 10210 | 10210 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 241 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation of meal service, the facility failed to provide services that respected resident's dignity during a random observation of a meal. Resident # 5 and 2 other unidentified residents were not served their meal in a timely manner. The findings included: The facility admitted Resident # 5 on 10/30/06 with [DIAGNOSES REDACTED]. On 11/16/10, at 12:20 PM, the lunch trays were delivered to the dining room. Resident # 5 was observed along with two other residents sitting in the dining room facing the other residents. Meal trays were served and the other residents ate or were assisted with their meals. Resident # 5's meal tray was noted to be on the cart. Resident # 5 and the other two residents were not assisted to a table or served the meal until 1:00 PM. This observation was shared with the DON during sharing. The facility admitted Resident # 3 on 6/23/10 with [DIAGNOSES REDACTED]. Prior to observation of wound care on 11-16-10 at 1:35 PM, Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #5 entered the room without knocking. During the course of the treatment from 1:35 PM until 2:55 PM, the LPN left the room two times to obtain needed supplies and reentered without knocking. The nurse entered the shared bathroom to wash her hands four times without knocking to ensure that residents from the adjoining room were not using the commode. At 2:30 PM, when the nurse entered the bathroom for the fifth time (without knocking) to wash her hands, she walked in on a resident who was using the commode. After this incident, the nurse continued to enter the bathroom door three more times without knocking while completing the wound care. The privacy curtain was not closed at the foot of the resident's bed during the entire treatment. During an interview with LPN # 3 on 11-17-10 at 12:40 PM, the nurse verified that she had failed to knock when entering the room and each time she entered the ba… | 2014-03-01 | ||
| 10211 | 10211 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 250 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, no medically related social services were provided for Residents #21 and #26 related to behaviors. ( 2 of 6 residents reviewed for specific medically related social services.) The findings included: The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed numerous nurse's notes documenting sexually inappropriate behaviors towards staff and residents and wandering into other resident rooms. This was also confirmed on 11/16/10 at 1:30 PM by 4 of 4 residents who attended group meeting. These residents stated they had been touched on the arms, toe, and asked "give me some sugar." Nurse's note on 5/18/10 documents " CNA (Certified Nursing Assistant) - resident touching and rubbing her leg - won't quit." On 5/25/10 " MD (Medical Doctor) in today for touching staff inappropriately. CNA reported resident asked for a kiss." On 5/26/10 note documents " CNA makes resident hold to side rails to keep him from reaching for her." Nurses notes continue: 6/12/10- touches staff inappropriately at times; 6/14/10 - started on Lexapro 10 mg (milligrams) r/t (related to) inappropriate sexual disinhibition; 6/16/10 - continues to enter resident rooms, continues to attempt to touch staff and residents- redirect as necessary; 9/1/10 CNA and PT (Physical Therapist) reported resident made inappropriate gestures and sexual comments. Resident attempted to enter other resident's rooms without permission; 9/4/10 - inappropriate sexual remarks at staff at times; 10/17/10 - staff and residents reported resident has been making inappropriate comments "give me some sugar and I want a lick." staff will continue to monitor behavior. On 11/16/10 resident approached a surveyor and asked "when can we meet" and made an explicit sexual gesture. Only two physician progress notes [REDACTED]. Review of Social Service Notes revealed a note on 4/22/10 -Resident has been not… | 2014-03-01 | ||
| 10212 | 10212 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 281 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide nursing services that met professional standards of practice. The facility nurse failed to transcribe Resident # 7's medication order correctly and multiple nurses administering medications to the resident failed to clarify the entry on the MAR (Medication Administration Record) for [MEDICATION NAME] as needed on Monday, Wednesday and Friday, resulting in a medication errors. The findings included: The facility admitted Resident # 7 on 11/10/10 with [DIAGNOSES REDACTED]. On 11/16/10, review of the resident's medical revealed a physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) revealed that the order had been transcribed incorrectly to the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. On 11/16/10 at approximately 4:00 PM interview with RN (Registered Nurse) # 4 revealed that she had transcribed the order incorrectly. She stated that the computer system being used will not recognize Monday, Wednesday, Friday orders unless entered as a prn order. She stated that she had failed to mark out the PRN as needed when the MAR indicated [REDACTED]. | 2014-03-01 | ||
| 10213 | 10213 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 279 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a plan of care which addressed the non compliance of Resident # 21 with safety regulations within the facility and failed to address the resident's non compliance with fluid restrictions. (One of one sampled resident known to be noncompliant with smoking regulations and one of one sampled resident reviewed with a fluid restriction reviewed for the development of care plans) The findings included: Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. On 11/14/10, at 6:50PM, the resident was observed to be out of bed sitting near the nurses station and in the dining room. The resident was observed to obtain glass(es) of water from a drinking cooler three times during the observation which lasted approximately one hour. No staff intervened or spoke with the resident about his fluid consumption. During an interview with the unit manager, when asked if the resident was compliant with the fluid restriction, she stated "no." The unit manager further verified that the resident's plan of care did not address his non-compliance or the facility plan to address the concern. Further record review revealed the resident had been noncompliant with the facility smoking regulations which had been addressed by the facility Administrator. On August 21, 2009 and on September 10, 2010, the resident had received a letter from the facility addressing his non-compliance. Nursing notes also revealed that on 9/16/10, two cigarette lighters had been removed from the resident's room. When the Administrator was questioned if he was aware of the 9/16/10 occurrence, he did not respond. Further review of the resident's comprehensive plan of care did not reveal any concern/plan related to the residents non-compliance with the facility safety/non-smoking regulations. A copy of the smoking policy (7/06) stated; "All residents are prohibited from keeping any type of smo… | 2014-03-01 | ||
| 10214 | 10214 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 309 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide physician-ordered care and services for one of two residents reviewed with orders for Hospice services and one of one residents reviewed for provision of [MEDICAL TREATMENT]. There was no evidence of implementation of a 10-6-10 hospital transfer order for Hospice for Resident #17. Intake and output was not monitored to ensure compliance with a fluid restriction order for Resident #21. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following a hospitalization from [DATE] to 10-6-10. Record review on 11-15-10 at 12:45 PM revealed a hospital Patient Transfer Form dated 10-6-10 which was noted as faxed to the facility on the same date. Instructions on the cover page of the form included to "Arrange hospice". Additionally, the same Discharge Instruction was listed as a line item on an attached Order Confirmation Report. There was no evidence in the medical record that the order had been implemented. During an interview on 11-15-10 at 3:30 PM, the Director of Nurses reviewed the transfer document and confirmed the order for Hospice. She stated she "did not see" and had not been aware of the order until 10-26-10, the date of the resident's death. During an interview on 11-16-10 at 11:35 AM, Registered Nurse (RN) #6 also confirmed the Hospice order and stated that she had been unaware of the Hospice order until after the resident's death when she "found the Hospice note". The RN stated that the transfer information usually came from the hospital in a packet and that the nurse who received the resident should have written the order for the referral. She stated that, when she became aware of the order, she questioned the nursing staff and they "said they never saw the order". The nurse further stated that the admitting nurse "should have made the referral". Resident # 21 was recently readmit… | 2014-03-01 | ||
| 10215 | 10215 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 314 | G | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, facility policy on care and assessment of Pressure Ulcers, and interview, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four of seven sampled residents reviewed for pressure ulcers. Resident # 23 was admitted [DATE] with a known pressure ulcer. treatment for [REDACTED]. Resident # 22 with a known red area to the back, receiving treatment, was not assessed weekly for changes in the area and effectiveness of treatment. Resident #1 failed to have ongoing documentation available of a pressure ulcer as it was treated to allow staff to accurately determine response to the treatment and the need for possible changes in treatment. During a pressure ulcer treatment observed on Resident #3 the licensed staff failed to implement infection control techniques to ensure healing. The findings included: The facility admitted Resident # 23 on 3/6/10 with [DIAGNOSES REDACTED]. On the weekly skin documentation form dated 3/6/10 the resident was documented by nursing to have a black area to the right heel with no further description/measurement noted. On 3/15/10 the area was documented as "soft and black." There was no physician order for [REDACTED]. ... He has a large decubitus over the right heel. It is covered by skin" . He previously had a blister and nursing staff reported that this has drained and there is some serosanguineous type drainage....Small area in the plantar surface of the right foot that is measuring approximately .5cm (centimeter) in diameter Wound bed in this area is pink, moist. This again is a very superficial area ..." The NP at this time ordered vitamin C, Prosource and Vitamin with Minerals, treatments to both areas, continued use of Podus boots, and floating of the heels while in bed. The physician saw the resident on 3/23/10 and made no change… | 2014-03-01 | ||
| 10216 | 10216 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 367 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide the diets as ordered by the physician for two of seven sampled residents reviewed for therapeutic diets. Resident #17 was provided solid foods on a mechanically-altered (pureed) diet and an order for [REDACTED]. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following hospitalization from [DATE] to 10-6-10 for Aspiration Pneumonia, Dehydration, and [MEDICAL CONDITION]. Additional/chronic [DIAGNOSES REDACTED]. Record review on 11-15-10 at 12:45 PM revealed that Resident #17 was on a "Puree diet with nectar thick liquids for pleasure" prior to hospitalization and received an "egg salad sandwich c (with) ea(ch) meal" per a physician's orders [REDACTED]. The hospital Patient Transfer Form dated 10-6-10 noted "Instructions" for a Discharge Diet of "TF (tube feeding)". The hospital Discharge Summary noted that the resident was to receive "[MEDICATION NAME] 1.5 at 80 ml (milliliters)/hour for 18 hours, start at 3 PM, off at 9 AM." physician's orders [REDACTED]. There was no evidence in the record that the sandwiches had been reordered. A copy of a Diet Order & Communication form dated 10-7-10 was found in the medical record. Pureed Texture and Nectar-Like Thickened Liquids were checked to indicate the type of diet to be provided. During an interview on 11-15-10 at 4 PM, the Speech Language Pathologist (SLP) reviewed the Rehabilitation Screen form she had completed on 10-8-10. She stated that the resident had been on caseload prior to the 9-26-10 hospitalization , but had reached a plateau. He had received the sandwich with meals prior to hospitalization and was "safe" with it. Upon readmission, she stated that the resident was uncooperative with the screening process for oral motor assessment and noted that the resident was "WFL (within functional limits) for puree". She did not request a… | 2014-03-01 | ||
| 10217 | 10217 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 156 | C | JNTL11 | On the days of the survey, based on record review and interview, the facility failed to provide Liability Notices to 3 of 3 residents reviewed for notification of Medicare Provider Non- Coverage. The facility did not utilize form or any of the 5 denial letters to inform residents or their responsible party of the items and services expected to be denied under Medicare Part A. The findings included: On 11/17/10 at 10:20 AM, a review of 3 random Medicare Non-Coverage Notices revealed that there were no Liability Notices included in the information given to the resident or responsible party. An interview with the Admission Coordinator revealed that she had not been aware until yesterday that Liability Notices were required. According to information provided by the Admission Coordinator, Resident A had used 50 days and his last covered day was 10/27/10 due to therapy being discontinued. Resident B had used 64 days and no longer required skilled services. His last covered day had been 9/2/10. Resident #8 had used 36 days and her last covered day had been 8/20/10 due to her therapy having been discontinued. | 2014-03-01 | ||
| 10218 | 10218 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 159 | D | JNTL11 | On the days of the survey, based on record review and interview, the facility co-mingled personal funds with facility funds for 2 of 5 residents reviewed with Resident Trust Fund Accounts. Resident D had personal funds withdrawn from her Trust Fund Account and deposited into the facility account. Resident E had retirement checks deposited into the facility account instead of being deposited into her Trust Fund Account first. In addition, there was no evidence of notification of balances that would jeopardize Medicaid eligibility for Resident D. The findings included: Review of Resident D's Trust Fund Account record on 11/17/10 at 1:42 PM revealed a Care Cost Payment dated 9/17/10 of $3.04, a second Care Cost Payment dated 10/7/10 for $11.28, and a third Care Cost Payment dated 11/5/10 for $30.06. When asked about what these payments were for, the Business Office Manager stated that she withdrew these amounts from the resident's Trust Fund Account and deposited the monies into the facility account since the resident had reached her $1800.00 limit in which she would need to start spending down her account since she was a Medicaid recipient. According to the Business Office Manager, the monies deposited into the facility account would go towards payment of any remaining balances the resident might have. When asked if the resident owed a balance, she stated "no". She stated the facility account was not interest bearing. When asked if she had contacted the family of the resident to try to see if they could spend down her account she stated she had never seen the family and hadn't recently tried to get ahold of them, but she would try now. Review of the Resident Fund Management Service reports revealed that these funds had been withdrawn from the resident's Trust Fund Account and had been deposited into the facility account. During the funds interview on 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that when a Medicaid resident's account reached #1800.00, she told the resident or responsible pa… | 2014-03-01 | ||
| 10219 | 10219 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 160 | D | JNTL11 | On the days of the survey, based on record review and interview, one of five resident records reviewed for conveyance of funds revealed disbursement of funds without written authorization. The findings included: On 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that Resident #19 had $30.00 in the Resident Trust Fund Account that had been sent to the funeral home at the family's request after her death. According to the Business Office Manager, the family wanted the cash money, however, she told them she could send it to the funeral home or the estate. The family requested the money sent to the funeral home. According to the Business Office Manager, there was no Power of Attorney in effect over the resident's financial matters. Review of the Admission Agreement revealed a "Beneficiary Designation:" section that was not filled out and did not designate a person to receive the resident's personal funds. | 2014-03-01 | ||
| 10220 | 10220 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 167 | C | JNTL11 | On the days of the survey, based on observations, the facility failed to post the most recent survey report within the facility. The facility failed to post the most recent complaint survey with citations from 9/16/10 and failed to post a complaint survey with citations from February 2010. The findings included: Observation on 11/15/10 at approximately 5:00 PM revealed a plastic holder mounted on the wall in the hallway near the front lobby. Observation of the contents of the holder revealed a labeled notebook containing the annual recertification survey report from September 2009. The complaint surveys with citations from 9/16/10 and February 2010 were not posted as required. On 11/17/10 at approximately 4:30 PM, the surveyor reviewed the contents of the notebook with the Administrator. The Administrator confirmed that the complaint surveys were not posted at that time. | 2014-03-01 | ||
| 10221 | 10221 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 282 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the care plan was not followed related to pacemaker checks for Resident #9 and analysis of causative factors of behavior for Resident # 26. ( 1 of 2 residents reviewed with pacemakers and 1 of 1 resident reviewed for socially inappropriate behaviors.) The findings included: The facility admitted Resident #9 on 5/13/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 revealed the resident to have a pacemaker. The Physician's History and Physical listed a [DIAGNOSES REDACTED]. Dates of 5/14/09, 9/3/09, 12/17/09 and 3/4/10 were listed on the sheet as to when checks should be done. The only documentation of testing in the medical record was dated 9/03/09. No other documentation could be found. There was no physician order to do pacemaker checks. The care plan for pacemaker also documented pacemaker check as ordered q 3 months ( every 3 months). An interview with RN # 1 (Registered Nurse) and the Unit Manager revealed that the nurse did not know the resident had a pacemaker. She was unable to find any information in the record related to the checks other than the one report of 9/03/09. RN #1 placed a call to the Clinic and found that a check had been done on 9/03/10. There were no other reports sent at this time. The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem which stated, "Resident exhibits socially inappropriate behaviors IE: wandering into others room, touching peers and staff inappropriately, pulling fire alarm. Under approaches were listed: assess resident's understanding of the situation, monitor resident frequently, analyze key times, places, circumstances, triggers, and what de-escalates behavior, and Psychiatric evaluation as indicated. An interview with the Unit Manager of 100 unit and Social Services on 11/17/10 revealed that no one had done an analysis, and no psychiatric evaluation had b… | 2014-03-01 | ||
| 10222 | 10222 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 441 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to provide evidence that all personal laundry was effectively cleansed/sanitized to destroy microorganisms. Also, based on observations and interviews, the facility failed to follow a procedure whereby expired topical agents, irrigation trays, and wound care supplies were removed from current stock and were available for daily use in two of four medication rooms reviewed. The findings included: During observation of the laundry on [DATE] at 10:15 AM, two home-type washers were noted (in use) not to be connected (via the chemical dispensing system) to any type of sanitizing agent. Bleach was set up to be dispensed on an automatic dispensing system to a third commercial-type washer. A sign was noted on the wall above a dryer indicating "no bleach" formula to be used on given wash cycles. When asked at this time, the Laundry Aide confirmed that bleach was not used for some personal laundry. She stated that the water temperature ranged from 120 to 160 degrees and was monitored by maintenance. She was unaware if any type of sanitizer was used and deferred to the Housekeeping Supervisor. During an interview on [DATE] at 2 PM, the Maintenance Supervisor provided laundry water temperature logs for review. Water temperatures ranged from 129 to 141 degrees Fahrenheit over the previous six month period. When informed that personal laundry was being washed without bleach, or water temperatures over 160 degrees, the Housekeeping Supervisor stated that he could provide no information to verify use of any other type of sanitizing agent. During an interview at 2:35 PM on [DATE], a second maintenance employee stated that he had checked the dispensing mechanism on the two home-type washers and that the commercial bleach product had not been connected. At that time, the Housekeeping Supervisor verified that he could provide no information on use of any type of sanitizing agent, … | 2014-03-01 |
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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 );