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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 609 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to report an allegation of abuse and injury of unknown source within the required time frame to the appropriate state agency as required for four of 14 sampled residents (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to report the allegation of verbal abuse to the state agency within the required two-hour time frame. On 12/02/18 a sewing needle was discovered in R4's wound on top of his/her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to report it to the state agency. On 01/08/19 R1 who was not cognitively intact experienced what the facility identified as an injury of unknown source; however, it was not reported to the state agency until 01/10/19 two days after the fact. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to report the misappropriation of the resident's medication within the required two-hour time frame to the state agency. Findings include: Review of R4's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18, revealed the facility assessed the resident to have a BIMS score of four out of fifteen, indicating the resident was severely cognitively impaired. During an interview on 01/20/19 at approximately 2:35 PM, the facility's Risk Manager (RM) revealed the incident of the sewing needle being discovered in R4's wound on her/his foot was not reported to the state agency as an injury of unknown source. The RM stated the resident could not tell how the needle got into the wound and it was not witnessed either. During an i… | 2020-09-01 |
| 2 | 2 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 610 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to ensure all allegations of abuse and injury of unknown sources were thoroughly investigated for four of 14 sampled residents reviewed for facility reported incidents (FRI's) (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to interview other residents of the facility. On 12/02/18 a sewing needle was discovered in R4's wound on top of her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to initiate an investigation. On 01/08/19 R1, who was not cognitively intact, experienced what the facility identified as an injury of unknown source; however, it was not thoroughly investigated. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to conduct a thorough investigation. Findings include: Review of R9's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS) completed on 11/05/18 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM. Review of the facility's Five-Day Follow-Up Report, dated 11/5/18, revealed Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 1 were the only staff interviewed about the incident. Additionally, there was no documented evidence interviewable residents in the facility… | 2020-09-01 |
| 3 | 3 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 755 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to assure that each cottages' narcotic medications that were locked in the cottages' medication cart corresponded with the cottages' narcotic count recorded in the narcotic book for two of 12 cottages. Findings include: On 01/18/19 at 4:30 PM, review of the narcotic medications that were locked in the locked compartment of the medication cart and in the presence of the Assistance Director of Nursing (ADON), Licensed Practical Nurse (LPN) 4 stated that Resident (R) 1 had nine tablets of [MEDICATION NAME]-ACET 5 mg (milligrams)-325 mg. However, R1's narcotic sheet for [MEDICATION NAME]-ACET 5 mg-325 mg tablet indicated 10 tablets. LPN4 stated that R1 had two tablets of [MEDICATION NAME] HCL 50 mg; however, review of R1's narcotic sheet for [MEDICATION NAME] HCL 50 mg tablet indicated three tablets. During an interview on 01/18/19 at 4:30 PM, LPN 4 stated that s/he gave R1 one [MEDICATION NAME] tablet when s/he returned from her/his doctor's appointment around 2 PM. LPN4 stated that s/he administered the [MEDICATION NAME] at 12 PM at the scheduled time. LPN4 stated that s/he forgot to document on each of the narcotic sheets that s/he had administered the medications. LPN 4 stated it was the facility's policy to document the administration of the medication after the medication was administered. Review of the Electronic Medication Administration Record (EMAR) with LPN4 and the ADON, revealed that there was no documentation that R1 had received one tablet of [MEDICATION NAME] at 2 PM; however, the [MEDICATION NAME] was documented as administered during the scheduled time at 12 PM. During an interview on 01/19/19 at 8:50 AM with the Administrator, ADON, and Unit Manger, the Unit Manager stated that s/he expected the nurses to document on the EMAR and, if applicable, the narcotic sheet immediately after administering any medication. Review of R15's Face She… | 2020-09-01 |
| 4 | 4 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 842 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to document in the resident's clinical record the nursing assessment of the physical condition for one of five residents reviewed for falls. (Resident (R) 2) after R2 fell from the mechanical lift to the floor. In addition, the facility failed to document the reason R2's physician was not notified for approximately one and one-half hours after the fall. Findings include: R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 24-hour Report dated 12/28/18 indicated the details of the incident that occurred on 12/27/18 at 7 PM, Resident was in Hoyer lift being placed back to bed. Hoyer lift clip cracked, and resident fell to the floor from an up position to her/his left side . Resident was sent to the ER. Review of R2's Progress Notes dated 12/27/18 at 2240 (11:40 PM) indicated, While CNA (certified nurse aide) was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . Resident requested to be sent to ER( emergency room ) . PCP (primary care physician) notified at 2034 (8:34 PM) and informed of incident and request to send to ER. EMS (Emergency Medical Services) arrived at 1906 (7:06 PM). Substitute POA (Power of Attorney) notified at 2234 (10:34 PM). Review of the document titled PACS Nursing - Post Fall Review, dated 12/27/18 at 6:50 PM, addressed that there was no history of falls; the medication the resident received were narcotics, diuretics, and laxatives; memory cognitively intact; adequate vision; total incontinence of urine and bowel movement; no behaviors in last seven days; confined to chair; no problems with blood pressure; and gait indicated unable to independently come to a standing position. The document did not d… | 2020-09-01 |
| 5 | 5 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 550 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide dignity and privacy for Resident # 41 by not covering the resident's catheter bag when it was in sight of other people. ( 1 of 2 residents observed with catheters) The findings included: The facility admitted Resident # 41 with [DIAGNOSES REDACTED]. On three days of the survey the resident was observed in bed in his/her room with the catheter tubing hanging uncovered on the side of the bed facing the door. The bag could be seen by anyone walking by the door or out in the dining area. Interview with the resident's spouse revealed the staff usually covered the bag but he/she had not seen the bag covered at all this week. Interview with Certified Nursing Assistant # 1 ( CNA) on 2/28/18 @ 10:15 AM revealed that the catheter bags were covered any time a resident was up or catheter bag was in view of other people to protect the privacy and dignity of the resident. When asked what he/she saw when he/she looked into this resident's room. He/she stated the catheter bag uncovered. The CNA confirmed the resident's privacy and dignity was not being protected. The CNA further stated, The cover was removed the other day and not replaced. There have not been any covers in the closet or in the cottage at all this week. The Licensed Practical Nurse #1 also responded that there were no covers in the cottage and that he/she would order some. | 2020-09-01 |
| 6 | 6 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 659 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide care per the Care Plan for Resident #18, 1 of 7 sampled residents reviewed for Falls. Resident #18 was care planned for the bed to be in low position and to remove bed controls due to the resident being a high fall risk. Cross refer to F689 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and then be found on the floor in the room. CNA #2 stated that when the bed is in normal position the resident is calm and content. Upon leaving the room, CNA #2 left the bed in normal position with the bed controls within reach of the resident. During an interview with Licensed Practical Nurse (LPN) #5 on 2/28/2017 at 3:06 PM, LPN #5 verbalized fall prevention interventions for Resident #18, including keeping the bed in lowest position. In addition, LPN #5 stated the resident is cognitively intact enough to op… | 2020-09-01 |
| 7 | 7 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 679 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a structured program of activities for 1 of 1 sampled resident reviewed/triggered for activities. Resident #82 was observed in bed in his/her room with no structured activities in progress. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Observations on 2/26/18 from 10 AM to 1 PM revealed Resident in room in bed with no structured program of activities provided. A record review on 2/26/18 at approximately 11:28 PM revealed documentation on a physician's capacity statement that Resident #82 was admitted on [DATE] and physician's cumulative orders that the resident was admitted on [DATE]. A social note dated 2/06/18 indicated the resident scored 15 cognition indicating cognition was intact and resident able to voice needs. Further record review revealed no activity evaluation was completed and there was no documentation on the paper charting or electronic record to indicate a structured program of activities were provided. An observation on 2/27/18 at approximately 11:33 PM to 1 PM revealed the resident in his/her room with no structured program of activities in place. A nurse's noted dated 2/06/18 indicated Resident #82 refused medication and verbally expressed he/she wanted to die. An interview on 2/28/18 at approximately 8:30 AM with Social Services Assistant #1 revealed the resident received psych services on 2/13/18. A review of the psych results revealed the resident depressed with a recommendation for staff to encourage residents to participate in activities. An interview on 2/28/18 at approximately 10:15 AM with the Activity Director (AD) confirmed the activity assessment/evaluation was not complete and there was no documentation in the medical record (paper/electronic) of activities being provided. | 2020-09-01 |
| 8 | 8 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 684 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services for 1 of 6 residents reviewed for unnecessary medications. Resident #115's elevated blood sugars were not reported to the physician as ordered. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Medication Administration Records for Resident #115 on 2/28/18 at approximately 11:12 AM revealed the resident had an elevated blood sugar of 410 on 2/23/18. Review of Resident #115's Progress Notes on 2/28/18 at approximately 11:50 AM revealed no documentation that the physician was notified of elevated blood sugar on 2/23/18. Interview with Director of Nursing (DON) on 2/28/18 at approximately 1:26 PM confirmed that there was no documentation that the elevated blood sugar on 2/23/18 was relayed to the physician. | 2020-09-01 |
| 9 | 9 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 689 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement fall prevention interventions for Resident #18, 1 of 7 sampled residents reviewed for falls. The facility failed to maintain the resident's bed in the lowest position and remove the bed controls per the Care Plan. Resident #18 has a history of multiple falls. Cross refer to F659 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Nurse's Notes on 2/28/2018 at 2:23 PM revealed that the resident had unwitnessed falls in her/his room on 10/30/2017, 11/25/2017, 12/27/2017 and 2/9/2018. In each case the resident was found on the floor near her/his bed. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. Review of the Certified Nursing Assistant task sheet for Resident #18 on 3/1/2018 at 10:25 AM, revealed a task to keep the resident's bed in low position. Removing the resident's bed controls was not listed on the task sheet. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and th… | 2020-09-01 |
| 10 | 10 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 732 | C | 0 | 1 | JK8711 | Based on observations, interviews and review of the facility's posting information, the facility failed to complete daily posting information that addressed nursing staff per shift. The posting did not identify whether nurse was registered or licensed and certified nursing to resident coverage was not included. 12 of 12 cottages. The findings included: During initial tour on 2/26/18 of the Forsythia Cottage at approximately 9:30 AM and the Rose Cottage at approximately 9:38 AM review of the hand written staff posting had no documentation of staff coverage related to the second shift (7 PM - 7:30 AM). Random observation on 2/27/18 at approximately 9 AM of the Rose Cottage and 9:30 AM of the Forsythia Cottage revealed the hand written staff posting noted on the wall with no second shift (7 PM - 7:30 AM) staff posted. An interview on 2/27/18 at approximately 12:15 PM with the Director of Nursing (DON) and Facility Administrator confirmed the second shift staff documentation was not posted for any of the cottages until the second shift staff arrived to the facility. Further review of hand written staff postings on the cottage revealed staff posting for 2/24/18 (Saturday) Rose Cottage first shift (7 AM - 7:30 PM) had no documentation of nursing staff coverage and the hand written on 2/25/18 (Sunday) Rose Cottage had no first shift staff coverage. The hand written staff posting for 2/25/18 (Sunday) Forsythia Cottage had no documentation of staff coverage. Review of the hand written posting indicated staff worked 12 and half hours shifts. During the survey, two family members expressed concerns about lack of evening and weekend staff coverage. During group interview on 2/27/18 at approximately 11 AM three of 5 residents who attend resident council regularly expressed concerns about staff coverage at nights and on weekends. A review of a computerized accounting of staff coverage for the past three months on 3/01/18 at 8:40 AM revealed a listing of staff coverage that was not accessible to residents/visitors/families. The… | 2020-09-01 |
| 11 | 11 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 745 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the communication sheet and interview, the facility failed to arrange and provide transportation to a medical appointment for Resident #121, 1 of 1 sampled resident reviewed for medically-related social services. Resident #121 missed a doctor's appointment due to the facility not arranging transportation. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. During an interview with Resident #121 and family member on 2/26/2018 at 10:00 AM, Resident #121 stated she/he had an upcoming appointment with his/her Oncologist on 2/28/2018. The family member stated she/he was concerned because the facility had provided no confirmation of transportation to the appointment. Resident #121 produced a form from his doctor with a list of upcoming appointments, including appointments on 2/28/2018 and 3/7/2018. During an interview with Licensed Practical Nurse (LPN) #3 on 2/26/2018 at 10:13 AM, LPN #3 was made aware of Resident #121 's and the family member's concerns related to the upcoming appointment on 2/28/2018. LPN #3 stated she/he would take care of the arrangements. On 2/28/2018 at 12:12 PM, LPN #4 was observed talking to another staff member about Resident #121's Oncology appointment. The staff member told LPN #4 that the Oncologist's office was calling asking why Resident #121 had not shown up for his/her appointment. LPN #4 then called the transporter (person in charge of setting up transportation). After the call, LPN #4 was interviewed and stated that transportation had not been arranged for the resident's appointment. LPN #4 stated transportation had been set up for an appointment on 3/7/2018, but not for today. During an interview with the Director of Nursing on 2/28/2018 at 2:00 PM, the DON confirmed that transportation had not been set up for the resident's appointment today. The DON stated LPN #3 reported to her/him that she/he called the transporter on 2/26 to see if transportation had been… | 2020-09-01 |
| 12 | 12 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 758 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor antipsychotic usage for 1 of 6 residents reviewed for unnecessary medications. Resident #115 was on antipsychotics and the facility failed to monitor him/her for side effects, behaviors, and nonpharmaceutical interventions. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #115's Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 2/28/18 at approximately 12:54 PM revealed the order for antipsychotic monitoring was discontinued by the physician. The DON was unable to clarify why the order had been discontinued. Interview with the DON on 2/28/18 at approximately 1:26 PM revealed the facility had resumed monitoring for antipsychotic medications. | 2020-09-01 |
| 13 | 13 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 842 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document a medical record (paper/electronic) for 1 of 42 sampled residents reviewed for advanced directives and clinical accuracy. Resident #82 paper charting was noted with full size red sheet of paper that indicated Do Not Resuscitate (DNR) and the electronic documentation indicated Cardiopulmonary Resuscitation (CPR). There was an inconsistency in the resident's admitted . The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. A review of the paper charting and electronic charting on [DATE] at approximately 11:28 AM revealed the resident's chart for advanced directive was coded as DNR and CPR. The paper charting was noted with a red sheet of paper that indicated DNR. The electronic record indicated the resident's advance directive was CPR (full code). Further review of the medical record review that one physician's signed resident's inability to consent on [DATE] and the second physician signed the inability to consent on [DATE]. The decisional capacity forms indicated Resident #82 was admitted on [DATE] and the Cumulative physician's orders [REDACTED]. An interview on [DATE] at approximately 12:09 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the paper chart indicated DNR and the computer documentation was CPR. | 2020-09-01 |
| 14 | 14 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 550 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that residents were treated with respect and dignity in three of 12 Cottages observed. Staff and/or contractor were observed entering residents' rooms without knocking. (Forsythia, Dogwood and Azalea) The findings included: An observation in the Forsythia Cottage on 5/13/19 at approximately 11:30 AM revealed Licensed Practical Nurse (LPN) #1 entering Resident #367 room without knocking. The resident was observed sitting in a wheelchair in his/her room. During an interview on 5/13/19 at approximately 11:33 AM with LPN #1 confirmed the observation. LPN #1 then smiled and knocked on the resident bedside table and playfully stated I have knocked now. A random observation in the Dogwood Cottage on 5/13/19 at approximately 3:13 PM revealed Activity staff entering room [ROOM NUMBER] without knocking. The resident was in the room in bed when the staff member entered the room. During an interview on 5/13/19 at approximately 3:18 PM with the Activity staff confirmed the observation. The Activity staff stated he/she does not generally knock on the resident's door if the door is opened and the resident is looking out toward the door. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:05 PM revealed a nurse entering room [ROOM NUMBER] without knocking. The resident was in the room in bed. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:21 PM revealed someone testing the alarms entering multiple residents' rooms without knocking. During an interview on 5/14/19 at approximately 12:25 PM revealed the alarm tester to be an Outside Fire Contractor who was entering the resident's rooms without knocking. | 2020-09-01 |
| 15 | 15 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 565 | E | 0 | 1 | Y5WG11 | Based on interviews and review of the Resident Council Minutes, the facility failed to ensure residents grievance were addressed related to staff being accessible in the cottages. Eight of eight group members and four months of resident council minutes. The findings included: During the agency group interview on 5/14/19 at approximately 10:32 AM eight of eight residents deemed alert, oriented and interview-able by the facility expressed concerns about staff being accessible in the cottages when needed. One resident stated that it takes several hours to see a nurse when needed because there may be one nurse at times who was responsible for rotating between three cottages. Another resident agreed that it takes staff a long time to address needs because staff rotate to other cottages. The resident who expressed concerns about one nurse covering three cottages stated he/she was not sure if one certified nursing aide had to cover three cottages as well. The residents stated they have addressed their concerns in resident council meetings. A review of the resident council minutes on 5/14/19 revealed at the 4/25/19 meeting there were concerns of getting medicine late due to nurse being in another cottage, certified nursing aides (CNA) on cells phone and certified nursing aides cutting off call lights saying they will return, and they do not return. The 3/27/19 resident meetings indicated medication was still being provided late, there are still issues with the certified nursing aides and staff not available to answer phones at night when family members are trying to contact the resident. The 2/28/19 resident meeting indicated concerns with late medications, CNA on cell phones. The (MONTH) 2019 minutes indicated concerns with late medications, cottages being un-staffed at night and CNAs telling residents they are alone in the cottages and unable to answer call lights. During an interview on 5/16/19 at approximately 8:16 AM with the Administrator revealed he/she was aware of the residents' concerns regarding staffing and t… | 2020-09-01 |
| 16 | 16 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 607 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's abuse policy, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hrs per policy for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported timely per the facility's abuse policy. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. A review of the facility's abuse policy under Reporting Timeframe, Abuse of any kind is to be reported within 2 hours by the facility as well as serious injury (which could fall under neglect or injury of unknown origin). Further review of the facility's policy under Role of the Investigator under 1(d) Interview any witnesses to the incident, 1(e) Interview the resident if medically possible and 1 (h) Interview family members. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19… | 2020-09-01 |
| 17 | 17 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 609 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hours for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported until 3/25/19. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19 but he/she does not know what time the incident occurred. RN #2 further stated the nurse who had been informed of the allegation of abuse did not include a date in his/her statement. During an interview on 5/15/19 at approximately 12:05 PM with RN #2 confirmed the allegation of abuse was not reported to the state agency within the 2 hours requirement per facility policy. | 2020-09-01 |
| 18 | 18 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 610 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were thoroughly investigation for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse had unsigned and undated witness statement and other staff members identified as being present at the time of the incident were not interviewed. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:35 AM with Registered Nurse (RN) #2 revealed the incident/allegation of abuse occurred on 3/24/19 but he/she does not know the time. RN#2 further confirmed the CNA/alleged perpetrator statement was unsigned and the nurse's statement was not dated. RN #2 confirmed there were no nurses notes to indicate when the resident/family reported the allegations of abuse. RN#2 further stated the new corporation had expressed that more accurate information was needed regarding allegations of abuse. | 2020-09-01 |
| 19 | 19 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 725 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient staffing for 2 of 12 cottages. Staff and residents expressed that the structure and layout of the cottages along with the insufficient staffing led to long wait times and inadequate care of residents. The findings included: Brushy Creek Rehabilitation and Healthcare Center consists of 12 cottages each with 12 beds. The only way to move between cottages is to traverse outside. Review of Grievance Log for Resident #67 on 5/15/19 at approximately 12 PM revealed that on 4/4/19 at approximately 2 PM the resident had rung his/her call light for assistance and walked away. The resident changed his/her own brief and filed a grievance. Review of Resident Council Minutes on 5/15/19 at approximately 12 PM revealed the following: 1. (MONTH) concerns expressed regarding CNA staffing 2. (MONTH) concerns regarding lack of CNAs in nurses and cottages; CNAs continue to tell the residents they are alone in the cottage and thus unable to answer the call button 3. (MONTH) concerns regarding nurses doing a good job but needed more help; CNAs are being split between cottages and care is limited at times and not enough CNAs for residents During an interview with Certified Nursing Aide (CNA) #1 on 5/15/19 at approximately 3 PM revealed during night shifts there often may be just one staff member (CNA) in a building because the nurse is attending to another cottage. During an interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 5/16/19 at approximately 9 AM revealed the following: 1. Sometimes during the night shift residents may fall because the CNA is busy with another resident in the cottage while the nurse is in another cottage and unable to assist. 2. During night shift, when two staff members are required for care s/he stated, If the nurse has two cottages they're called over. If they have three cottages they're called over, but it may take longer. 3. LPN #2 stated she has exp… | 2020-09-01 |
| 20 | 20 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 812 | E | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure that food was stored, prepared and distributed in an appropriate manner for 5 of 12 Cottages observed for kitchen services. Holly, Magnolia, and Rose Cottages had expired food and foods that were opened with no open date. Magnolia and Rose Cottages were observed with resident's personal food in the refrigerator used by the cook which was against facility policy. The Dogwood Cottage Kitchen had staff preparing meals with facial hair uncovered (thick mustache). The Azalea Cottage Kitchen had staff preparing meals with large trash can with no lid available. The findings included: During the initial tour of Holly Cottage with the Registered Dietitian (RD) on [DATE] at approximately 10:10 AM, butter was observed in the freezer with an expiration date of [DATE]. The expiration date was verified by the RD at the time of the observation. During the initial tour of Magnolia Cottage with the RD on [DATE] at approximately 10:40 AM, Lemon juice was observed in the kitchen area with an expiration date of [DATE]. Also, during the tour, cooking spray, granulated garlic, and ground cinnamon were observed in the kitchen area without dates opened for use. As the tour continued, Paprika had an opened-on date of [DATE], steak seasoning had an opened-on date of [DATE], basil had an opened-on date of [DATE] and vanilla extract had an opened-on date of [DATE]. The expiration date of the lemon juice was verified by the RD at the time of observation. The lack of opened-on dates for the cooking spray, granulated garlic, and ground cinnamon was verified by the RD at the time of observation. When asked about the older opened-on dates, the RD stated that the items should have been thrown out after a year or at expiration. A resident's personal food was observed in the kitchen refrigerator of Magnolia Cottage. This was verified by the RD at the time of observation. During the initial tour … | 2020-09-01 |
| 21 | 21 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 842 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy the facility failed to maintain a complete and accurate medical record for Residents #366 and 365, 2 of 27 sampled residents reviewed for complete and accurate records. Resident #365's record did not have complete and accurate documentation related to an incident of alleged abuse. Resident #366's record lacked documentation related to controlled substance medication administration. The findings included: The facility admitted Resident #366 with [DIAGNOSES REDACTED]. Review of a Facility Reported Incident on 5/15/19 at 1:49 PM revealed Resident #366's pain medication [MEDICATION NAME] 50 milligrams (mg) was accidentally placed in a bin for discontinued medications on 4/21/19. After a complete investigation by the facility, the medication was found on 4/23/19. Record review of Medication Administration Records (MAR) and narcotic count sheets on 5/15/19 at 1:51 PM revealed an order for [REDACTED]. The narcotic count sheets revealed the resident's 4/21/19 morning dose of [MEDICATION NAME] was signed out at 8:50 AM and administered to the resident per the MAR. The narcotic count sheets revealed the 2 tablets of [MEDICATION NAME] 50mg were signed out on 2 separate occasions on 4/23/19. The time the [MEDICATION NAME] was signed out was not documented by either nurse signing out the [MEDICATION NAME] on 4/23/19. Record review of notes from the MAR on 5/16/19 at 9:12 AM revealed 2 tablets of [MEDICATION NAME] were administered to Resident #366 on 4/23/19 at 5:06 PM and 10:13 PM, about 5 hours apart. The orders were to receive the [MEDICATION NAME] every 12 hours. During an interview with the Assistant Director of Nursing (ADON) on 5/15/19 at 2:26 PM, the ADON confirmed the narcotic count sheets did not indicate what time Resident #366 [MEDICATION NAME] was signed out on 4/23/19. The ADON stated the resident's [MEDICATION NAME] was found around 4:00 PM on 4/23/19 and the resident request… | 2020-09-01 |
| 22 | 22 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-06-26 | 609 | E | 1 | 0 | Y9Q111 | > Based on record review, interview, and review of the facility policy titled Reporting of Alleged Abuse to Facility Management, the facility failed to report injuries of unknown source to the State Agency for 2 of 3 sampled residents reviewed for abuse. The facility failed to report injuries of unknown source for Resident #2 and Resident #3 to the state agency. The findings included: Review of Resident #2's health status note dated 5/30/18 revealed a note from the Risk Manager which stated Resident has a 1.5mm purple discoloration to his/her right bottom inner eye. Residents reports s/he is not really sure how it could have happened nor did s/he know it was there but s/he stated 'Oh it could have happened by rubbing my eye, it doesn't hurt, so don't worry about it' Will continue to monitor. Review of the facility incident report for resident #2 dated 6/19/18 reveled the incident description section which stated I was called to Resident room today regarding bruising to bilateral hands with bruising extending from left hand to left forearm. Resident is alert and orientated and stated I don't know how it happened but I pull my table over, eat all my meals in my bed with the tray on my lap, I have arthritis but no, my hands don't hurt. Review of Resident #2's progress notes dated 6/19/18 revealed a note from a Licensed Practical Nurse (LPN) which stated Unidentified bruising on patients top right and left hand. The CNA (Certified Nursing Assistant) noticed as s/he came on for the 7a-7p shift today and brought it to my attention. Patient appears to be in no pain at this time. __ __ in risk management was notified, visited the patient and said s/he would document on the incident. Will continue to monitor. Review of the facility incident report for Resident #3 dated 4/28/2018 revealed the incident description section which stated Yellow/brownish bruise to Left FA new AC Reddish 7cm bruise to med, right back Resident stated s/he thought is may have occurred when s/he wrapped arm around bed rail to assist with turning/re… | 2020-09-01 |
| 23 | 23 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 224 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Abuse policy and interview, the facility failed to conduct a thorough investigation for Resident #1, 1 of 3 sampled residents reviewed for Injury of Unknown Source. Resident #1 suffered a fracture of unknown origin. The facility failed to interview and obtain statements from direct care staff who provided care for Resident #1, on or around the time the resident suffered the fracture. The cause or exact date of the fracture could not be determined. Cross refer to F225 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. Record review of the Five-Day Follow-Up Report, dated 4/4/ on 8/23/2017 at 9:40 AM revealed the resident suffered an acute non-displaced left fibula and tibial shaft fracture. The injury was discovered on 3/30/2017 at 12:00 AM. Per the Five-Day Follow-Up Report, Resident #1 complained of pain to the left leg with repositioning on 3/29/2017. The resident was able to move her/his left leg. The resident also had a witnessed [MEDICAL CONDITION] on 3/27/2017. In addition, staff attempted to obtain a urine sample on 3/27/2017 via a in and out catheter. Per the report, the resident became very combative with thrashing around in bed while his/her legs were trying to be abducted. The resident spent all day in bed with intermittent diarrhea 3/28/2017. The facility's investigation concluded that the fracture appeared to be the result of the combative behavior during the in and out catheter procedure. Record review of the Telephone Orders on 8/23/2017 at 10:08 AM revealed an order, dated 3/27/2017 at 4:00 PM, for a in and out catheter to obtain a urine sample for urinalysis. A Telephone Order dated 3/28/2017 discontinued the in and out catheter order. Record review of the Medication Administr… | 2020-09-01 |
| 24 | 24 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 225 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse policy, the facility failed to report an Injury of Unknown Source that resulted in serious bodily injury for 2 of 3 sampled residents reviewed for Injury of Unknown Source. Resident's #1 and #2 suffered fractures and the injuries were reported later than 2 hours. Cross refer to F 224 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. The resident suffered a fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 3/30/2017 at 11:45 AM. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 4/28//2017, on 8/23/2017 at 9:40 AM revealed Resident #2 suffered an injury of unknown source on 4/28/2017 at 9:00 AM. Resident #2 suffered a left arm fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 4/28/2017 at 1:59 PM. During an interview with the risk manager on 8/23/2017 at 12:31 PM, the risk manager confirmed that the injuries of unknown origin were reported later than 2 hours. The Risk Manager stated she/he is aware of the 2-hour reporting requirement. Review of the facility's Reporting Abuse to State Agencies and Other Entities policy revealed Should a suspected crime resulting in serious bodily injury, the employee shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. | 2020-09-01 |
| 25 | 25 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 282 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow the nutrition care plan for 1 of 1 sampled resident for hospice. Dietary approaches for a low fiber diet with ground meat and nectar-thickened liquids was not followed for Resident #265. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of nutrition care plan on 11/29/2016 revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 26 | 26 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 309 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure integration of Hospice and facility services to provide continuity of care for 1 of 1 sampled resident reviewed for Hospice. Complete documentation could not be found in Resident #265's medical record for Hospice services provided and there was no evidence of communication between Hospice and the facility to establish an agreed upon/coordinated plan of care. The findings include: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review on 11/29/2016 of Hospice documentation, kept in a separate notebook from the medical chart, revealed the Hospice Care Plan for Nurse visits weekly, Aide visits three times a week, Chaplin visits once a month, and Social Worker visits once a month. Record review on 11/29/2016 revealed incomplete documentation for Hospice Aide visits between 08/23/2016 and 11/17/2016, incomplete documentation for Chaplin visits for (MONTH) (YEAR), and incomplete documentation for Social Worker visits for (MONTH) (YEAR). During an interview on 11/29/2016 at 4:04 PM the Director of Social Services verified missing Hospice documentation. The Director of Social Services verified that at the time of services, Hospice notes were to be documented in Resident #265 ' s Hospice record. Review on 11/29/2016 of the Skilled Nursing Facility Service Agreement with the Hospice provider verified each party is responsible for documenting such communication in its respective clinical records to ensure that the need of hospice patients are met twenty-four hours per day. During an interview on 11/30/2016 at 12:15 PM revealed no evidence of care plan integration. Registered Nurse (RN) #1 verified that the facility staff did not review the Hospice care plan and that Hospice was only included in the facility care plan interventions under nutrition. RN #1 verified that Hospice services were not included in the interdisciplinary care plan and that Hospice did not attend the … | 2020-09-01 |
| 27 | 27 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 323 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that the planned fall prevention measures were in place and/or changed/added to prevent reoccurrence and minimize potential injury for 1 of 2 sampled Residents for accidents. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of fall risk assessment on 11/28/2016 revealed that Resident #265 was a high fall risk. Fall assessment dates and scores; 08/05/2016 score 10, 08/25/2016 score 10, 11/16/16 score 16. Review of Nurses notes, incident reports, and care plan revealed that Resident #265 had falls on the following dates: 9/28/16- Fall in bedroom. My knees are red but my ROM is WNL. Please place laser alarm on floor for poor safety awareness. 10/13/16- I lost balance in bathroom going into room CNA lowered me to floor. 10/23/16- Continue bed/chair alarms non skid socks. 10/28/16- Fall in bedroom Laser alarm by bed, re-educate on not turning off alarms and calling for assistance with any transfers. Nurses notes dated 10/28/2016 stated alarm not sounding r/t elder shuts it off. 11/8/16- I slid down to floor when trying to transfer self from WC to chair; no injury noted. 11/16/16- Slid out of bed onto floor with no injury noted. Implement fall mat, ensure alarms are functioning Q shift. 11/21/16- New alarms to bed and chair with no turn off switch. Observation on 11/28/2016 at 12:00 PM revealed no fall mat in Resident #265 ' s room, bed alarm with turn off switch, and laser alarm was turned off. The resident was lying in bed. Observation on 11/29/2016 at 12:35 PM revealed no fall mat in Resident #265 ' s room, and bed alarm with turn off switch. The resident was lying in bed. Observation on 11/30/2016 at 12:00 PM revealed no fall mat in resident #265 ' s room, bed alarm with turn off switch, and wheel chair alarm with turn off switch. Resident #265 was sitting in wheelchair in common area. The Director of Nursing (DON) and Re… | 2020-09-01 |
| 28 | 28 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 329 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 of 1 sampled resident reviewed for Hospice had documented clinical reason for medication administration and/or were monitored for effectiveness of medication for Resident #265. Resident #265 was prescribed medication for which there was no documented evidence of clinical need. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/30/2016 at 9:30 AM revealed physician's orders [REDACTED]. 4 hours , [MEDICATION NAME] 0.5 mg tablet one tablet every 6 hours as needed , and Vitamin D3 1,000 units tablet 2 tablets daily . Continued review revealed no clinical indication for Vitamin D3 to treat the Resident's assessed condition. There were no laboratory reports to substantiate Vitamin D3 deficiencies or reason for continued use. No documented evaluation of the underlying cause of behaviors prior to the start of psychiatric medications. No pain measurement tool documented prior to [MEDICATION NAME] administration and after administration to measure effectiveness. No documentation of behaviors prior to administrating [MEDICATION NAME] and [MEDICATION NAME]. Review of the Medication Administration Records (MARs) revealed that from 09/01/2016 through 11/27/2016 Resident #265 received 18 doses of as needed [MEDICATION NAME] 0.5mg tab, 7 doses of as needed [MEDICATION NAME] 5mg/ml 0.5 ml, and 100 doses of as needed [MEDICATION NAME] 50 mg tab. Review of Progress Notes and MARs revealed that no reason for administration and/or effectiveness of PRN (as needed) medication were documented. Continued review revealed no evidence of evaluation of underlying cause of behaviors prior to starting routine psychiatric medications. During an interview on 11/30/2016 at 9:40 AM with the Director of Nursing (DON) information was requested to provide clinical reasons for the use of Vitamin D3. The DON stated they had reviewed the medical records a… | 2020-09-01 |
| 29 | 29 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 367 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to assure that 1 of 1 sampled Residents reviewed for Hospice received the diet that was prescribed by the Physician. Resident #265 ' s physician's order [REDACTED]. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 30 | 30 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 371 | E | 0 | 1 | OHU211 | Based on observation and interview, the facility failed to assure foods were held at appropriate temperatures prior to serving in 2 of 2 cottages. In the Dogwood cottage, staff failed to calibrate the thermometer. In the Azalea cottage staff served foods that had been held at improper temperatures. Observation of the Azalea cottage at approximately 12:10 to 12:20 PM on 11/29/16 revealed Cook #1 measured the temperature of peaches, a cold food item, to be 49 degrees Fahrenheit. The cook did not alert the Certified Nursing Assistant (CNA) #3, who was serving, that the cold food item did not reach appropriate temperatures. Observation of the Azalea cottage at approximately 12:50 on 11/29/16 revealed that during the meal, the cold food item was held on the table without refrigeration or insulation. When CNA #3 plated four helpings of peaches and began serving, she was stopped and informed that they were not held at appropriate temperatures. Observation on 11/28/16 at 12:03 PM revealed Certified Nursing Assistant (CAN) #2 and Licensed Practical Nurse (LPN) #1 starting to plate lunch without taking food temperatures. When asked if food temperatures had been taken the staff were unaware that this had to be done. Observation on 11/28/2016 at 12:10 PM Dietary Aide #1 checked the temperature of the fish, without calibrating the thermometer. When asked Dietary Aide #1 stated that she/he calibrated the thermometer by placing it in ice water. When asked what temperature, the thermometer should be calibrated to she/he stated till it reads 0 degrees Fahrenheit. Cook #1 stated that after the thermometer was placed in ice water, it should read 32 degrees Fahrenheit. Observation on 11/28/2016 at 12:17 PM, Dietary Aide #1 filled a cup with ice and water and inserted the thermometer. When checked by Cook #1 the thermometer read 42 degrees Fahrenheit. She/He stated that the thermometer was calibrated earlier in the day and read 41.5 degrees Fahrenheit. Cook #1 stated that the Certified Dietary Manager (CDM) would need to be contacted… | 2020-09-01 |
| 4805 | 4805 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2015-12-16 | 309 | D | 0 | 1 | 7KL211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that hospice documentation was accessible for 1 of 1 sampled resident reviewed receiving hospice services. Resident #240's documentation of Hospice Nurse, Certified Nursing Aide, Social Worker and Chaplin visits were not in the medical record or available in the facility. The findings included: The facility admitted Resident #240 with [DIAGNOSES REDACTED]. A review of the medical record on 12/16/15 at approximately 11:47 AM revealed Resident #240 was admitted to hospice 8/28/15. Further record review revealed there was no documentation in the chart to verify the resident had been receiving regular visits by a Hospice Nurse, Certified Nurse Aide, Social Worker and Chaplin. An interview on 12/16/15 at approximately 12:10 PM with the Social Service Director (SSD) revealed the staff was in the process of going through the thinned charts to locate the documentation of hospice visits. An interview on 12/16/15 at approximately 12:53 PM with the SSD revealed the facility staff was still in progress of getting the documentation of hospice visits. On 12/16/15 at approximately 1:15 PM the SSD provided faxed documentation of hospice visits for the months of Sept and (MONTH) (YEAR). There was no documentation of regular visits for the month of (MONTH) (YEAR) by the Hospice Certified Nurse Aide, Social Worker or Chaplin. There was no documentation of regular visits by the Hospice Certified Nurse Aide for (MONTH) (YEAR). | 2019-07-01 |
| 4806 | 4806 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2015-12-16 | 371 | E | 0 | 1 | 7KL211 | Based on observations, interviews and review of the facility policy FOOD/NUTRITION DEPARTMENT INFECTION CONTROL, the facility failed to ensure that food was prepared and served in a sanitary manner. Dietary/Cook/Certified Aides staff were observed in four (4) of twelve (12) cottages with hair restraints not worn appropriately while in the kitchenette of cottages where food was prepared, not worn appropriately when food was prepared and not worn appropriately while putting food in plates to serve to residents. Staff in Crepe Myrtle, Jasmine, Camellia and Dogwood Cottages did not have hair covered appropriately. The findings included: During initial tour on 12/14/15 at approximately 10:15 AM staff in the kitchenette in Jasmine Cottage were observed with the side of hair not covered by hair net. At approximately 10:25 AM staff were observed in the kitchenette in Camilla without appropriate hair coverage. At approximately 10:30 AM staff were observed in Dogwood cottage with hair not covered under the hair net being worn. During random observation in the Camellia Cottage on 12/15/15 at approximately 9:01 AM two (2) Certified Aides were observed in the kitchenette where food was prepared without hair nets covering their hair properly. Staff were observed with the side of their hair uncovered by the hair net worn. During observation of the lunch preparation on 12/15/15 at approximately 11:10 AM, the cook was observed in the kitchenette in Jasmine Cottage preparing food for residents in Jasmine and Crepe Myrtle Cottages without a hair net covering the side of hair. During observation of the lunch meal served in Crepe Myrtle Cottage on 12/15/15 at approximately 12:20 PM, the cook and dietary/certified nurse aide did not have hair covered to prevent hair from falling in resident's food. The dietary staff/nurse aide did not have the front of his/her hair covered and the cook did not have the side of his/her hair covered under the hair net. During an interview on 12/15/15 at approximately 12:30 PM with the cook and dietary/n… | 2019-07-01 |
| 6243 | 6243 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 156 | C | 0 | 1 | 0BDJ11 | Based on record review and interviews, the facility failed to provide either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS- ) or one of the five uniform Denial Letters to Residents #4, #5, and #15, 3 of 3 residents reviewed for liability notices that had a change in payer source with Medicare days remaining. The findings included: On 9/4/14 at approximately 11:00 AM, review of the liability notices revealed no Advanced Beneficiary Notice (Form CMS- ) or one of the five uniform Denial Letters had been provided to Residents #4, #5, or #15, who had a change in payer with Medicare A days remaining. During an interview at that time, LBSW (Licensed Bachelor's Social Worker) #2 stated s/he would look into the concern. LBSW #2 returned to the business office with LBSW #1 who stated that therapy provided the CMS- forms. When asked for the forms for the 3 residents, LBSW #2 stated They're Medicare A (residents). After confirming the payer source with the LBSW, s/he then questioned if the letters had to be given to Medicare A residents. The LBSW stated s/he would investigate and provide additional information. No further information was provided. | 2018-04-01 |
| 6244 | 6244 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 159 | C | 0 | 1 | 0BDJ11 | Based on record review, interviews, and review of the facility's policy, Resident Funds, the facility failed to deposit residents' personal funds in excess of $50 in an interest bearing account for Resident #20, #23, #A and #B, 4 of 10 residents reviewed with a resident trust fund. The findings included: On 9/4/14 at approximately 2:15 PM, review of the resident's trust fund accounts revealed Resident #20 had an account balance of $97.79, #23 had a balance of $90.00, Resident A had a balance of $60.00, and #B's account balance was 100.00. During an interview at 3:45 PM, the Account Specialist confirmed the 4 resident had trust fund account balances, being held by the facility, in excess of $50.00 and were not in an interest bearing account. The Account Specialist also stated s/he thought that a resident who was private pay could have up to $100.00 before it had to be deposited in an interest bearing account. Review of the facility's policy, Trust Funds, revealed 1. Our business office will deposit any Resident's personal funds in excess of $50 in an interest bearing account that is separate from any of the facility's operating accounts, and that credits all interest earned on that account to his/her account. | 2018-04-01 |
| 6245 | 6245 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 160 | B | 0 | 1 | 0BDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy, Resident Funds, the facility failed to convey funds deposited with the facility to the estate of the resident or to the probate court for Resident #C and #D, 2 of 3 residents reviewed for conveyance of funds. The findings included: On [DATE] at 11:13 AM, review of the conveyance of funds upon the death of Residents C revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the Power of Attorney (POA) on [DATE]. Review of review of the conveyance of funds upon the death of Residents D revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the POA on [DATE]. During an interview at that time, the Business Analyst confirmed the trust fund balances were paid to the Power of Attorney for both Residents. The Account Specialist confirmed They're supposed to go to the Estate of. When asked why the accounts were paid to the POA, the Account Specialist stated that the Power of Attorney for both residents had deposited $50.00 in the residents' account just in case. Upon the residents' death the POA for both residents had requested the money, stating it was their money in the first place and s/he had paid out the accounts, in cash, to the POA in both instances. Review of the facility's policy, Trust Funds, revealed Upon the death of a Resident with a personal fund, the business office will convey within 30 days the Resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the Resident's estate. | 2018-04-01 |
| 6246 | 6246 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 226 | D | 0 | 1 | 0BDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime, and interview, the facility failed to implement their abuse policy by not reporting an alleged abuse timely and developing a plan of action to protect Resident #7 from potential harm. 1 of 3 reportable's reviewed for alleged abuse. The findings included: The facility admitted Resident #7 with a [DIAGNOSES REDACTED]. On 09/03/14 at approximately 10:50 AM a review of the 07/07/14 Quarterly Minimum Data Set (MDS) revealed the resident had a Basic Individual Mental Status (BIMS) score of 3, indicating that the resident was severely cognitively impaired. On 09/03/14 at approximately 11:00 AM a review of an investigative report sent to the State Agency by the facility on 06/16/14 revealed three separate occurrences of a visitor allegedly having inappropriate interactions with Resident #7. The first incident reported by Licensed Practical Nurse (LPN) #1 occurred on 06/12/14 stated a visitor had exhibited inappropriate behaviors toward Resident #7, including fondling of the breast and kissing the resident. LPN #1 stated s/he had observed the visitor on two separate occasions (06/12/14 and 06/14/14) in the common area of Dogwood Cottage giving a peck kiss to Resident #7 on the mouth and brushing up against resident's breast with part of his/her hand and arm while hugging resident. LPN #1 stated that on 06/13/14, visitor and wife were sitting to the left side of the common area and Resident #7 was sitting on the right side of the common area. The visitor got up from a chair and wheeled Resident #7 over to where the visitor and wife was sitting. The visitor placed Resident #7 on the right and sat in the middle. The Certified Nursing Assistant (CNA) removed Resident #7 away from the visitor. The investigative report also revealed that LPN #1 had reported the incident to Social Worker #1 and the Nursing S… | 2018-04-01 |
| 6247 | 6247 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 250 | D | 0 | 1 | 0BDJ11 | Based on facility's investigative report review, facility policy entitled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime, and interview, the facility failed to provide appropriate medically-related social services to protect 1 of 3 residents reviewed for abuse/neglect. Resident #7 was not protected from improper interactions by another resident's husband after the initial incident of inappropriate touching occurred. Cross refer to F 226 as it relates to the provision of social services related to an allegation of potential abuse. The findings included: On 09/03/14 at approximately 11:00AM review of the facility's investigative report dated 06/17/14 revealed that on 06/12/14, Licensed Practical Nurse (LPN) #1 had witnessed Resident #3's husband approach Resident #7, lean down and give her/him a peck kiss on the lips. LPN #1 also observed Resident #3's husband go to the right side of Resident #7's wheelchair, bend over towards the resident, place his right hand under her armpit as to hug her, then moved right hand across her chest area jiggling the right breast, stood up and went back to his chair. LPN #1 later notified the Social Worker of the episode. LPN #1 was informed by the Social Worker to chart, keep a watchful eye, and that s/he would figure out how to inform the families. Review of the facility's abuse policy on 09/03/14 at approximately 11:30 AM revealed that procedures to protect the residents included to remove staff, visitors, volunteers, family members and others alleged to have abused a resident from the facility until the matter is investigated and resolved. The policy also stated to report any incidents to the Administrator, the Director of Nurses and the proper authorities immediately. This was not done and two more incidents with the other resident's husband and Resident #7 occurred. During an interview with the Administrator on 09/04/14 at approximately 10:15 AM, s/he confirmed that Social Worker #1 had not followed the facility policy to notify manag… | 2018-04-01 |
| 6248 | 6248 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 280 | D | 0 | 1 | 0BDJ11 | Based on record review, and interview, the facility failed to update the comprehensive care plans to reflect the current needs of the residents for 1 of 15 sampled residents reviewed for care plans. Resident #7's care plan did not reflect the alleged incident of sexual abuse and interventions to ensure safety of the resident from another resident's visitor. Cross Refer to F 226 as it relates alleged abuse of Resident #7 and failure of the facility to put interventions in place to protect the resident. The findings included: Review of Resident #7's Care Plan on 09/04/14 at approximately 3:30 PM revealed that the Care Plan was reviewed and revised by the Interdisciplinary Team, including Social Services and Nursing. An allegation of abuse related to inappropriate touching by a visitor was reported on 06/12/14. Resident #7's Care Plan was documented as reviewed before the incident on 04/17/14 and after the incident on 07/15/14. During an interview on 09/04/14 at approximately 3:30 PM with the Minimum Data Set (MDS) Assessment Nurse confirmed that the Care Plan received by the surveyor for Resident #7 was current and was not updated to include specific interventions to protect the resident and prevent recurrence. | 2018-04-01 |
| 6249 | 6249 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 514 | D | 0 | 1 | 0BDJ11 | Based on review of the facility's investigative report, record review, and interviews the facility failed to provide accurate documentation relating to an alleged abuse of 1 of 3 reportable's reviewed for alleged abuse. Documentation of alleged abuse incidents by another resident's visitor and Resident #7 varied. Conflicting statements in the facility's investigative report made it difficult to make an accurate assessment of the alleged incident. Cross Refer to F 226 as it relates to alleged abuse of Resident #7 and failure of the facility to report timely and put interventions in place to protect the resident. The findings included: On 09/03/14 at approximately 10:50 AM review of the Nurses Notes dated 06/12/14 reflected fondling of Resident #7's breast by another resident's visitor. On 09/03/14 at approximately 11:00 AM review of the facility investigative report reflected a clarification of another resident's visitor brushing up against breast. During an interview with LPN #1 on 09/03/14 at approximately 11:40 AM, s/he stated s/he actually saw another resident's visitor move hand across upper abdomen, hugged and gave a short peck kiss on Resident #7's lips. Statements in the investigative report and Nurse's Notes had conflicting documentation. | 2018-04-01 |
| 6437 | 6437 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2015-02-10 | 314 | G | 1 | 0 | Q7ND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that a resident does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Resident #1 developed a Stage 2 pressure ulcer to the sacrum when the resident's air mattress was unplugged and deflated. There was no documentation of when the air mattress was found deflated or that the nurse assessed the resident at the time of the discovery. There was no order for treatment for [REDACTED]. One of one resident's reviewed for pressure ulcer. The findings included: Review of Resident #1's medical record revealed a Wound Care Progress Note dated 11/6/14 at 12:07 that indicated Elder now with Stage 2 FA PU (pressure ulcer) to sacrococcygeal area 10 cm (centimeters) x 5 cm. Butterfly with irregularity. Wound bed beefy red - small amount of bleeding with cleansing. Edges are flat. Is on air mattress. Air mattress found unplugged Tuesday night on 3rd shift . The RN Clinical Nurse Specialist stated the Tuesday night was on 11/4/14 during the 11:00 PM - 7:00 AM shift. Review of Resident #1's Nurse's Notes dated 11/4/14 revealed no documentation related to the resident's air mattress being found unplugged. There was no documentation of when the air mattress was found deflated or that the nurse assessed the resident's skin at the time of the incident. A Nurse's Note dated 11/4/14 at 10:02 AM indicated the RN Clinical Nurse Specialist completed a brief assessment of Resident #1 after the nurse's report. The RN Clinical Nurse Specialist noted [MEDICAL CONDITION] to the inner aspect of the right eye. In an interview with the surveyor on 2/10/15 at approximately 4:12 PM, the RN Clinical Nurse Specialist stated that s/he examined Resident #1 related to concerns of [MEDICAL CONDITION] and the resident's level of response. The RN Clinical Nurse Specialist did not assess the resident related to the air mattress being found unplugged. Review of Re… | 2018-02-01 |
| 7530 | 7530 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2013-05-01 | 441 | E | 0 | 1 | 9H2211 | On the days of the survey, based on observation and interviews, the facility failed to handle soiled linen properly during the sorting process and use required amount of detergent so as to prevent the spread of infection. The facility also failed to transport clean linen properly to prevent contamination. (4 of 12 Cottages). The finding included: During observation of the sorting of soiled linen and residents' personal clothing in the Rose Cottage on 4/30/13 at approximately 12:30 PM, the CNA (Certified Nursing Assistant) #2 was observed using disposable wrist length gloves and no apron/gown. After sorting the linen, CNA #2 was observed putting laundry detergent and fabric softener into a plastic cup. The plastic cup had no measurements to indicate how much detergent was being used. There was a sign indicating that two pumps of the bottle would amount to two ounces of detergent which was recommended. The surveyor observed a measuring cup and asked the CNA to pour the detergent that was in the plastic cup into the measuring cup. The measuring cup indicated there was only 1 oz of detergent being used. Further observation of the laundry process revealed CNA #2 adding the detergent and fabric softener on the residents' clothing instead of the designated ports. During an interview with CNA #2, she/he verified the correct amount of detergent was not measured and color coded measuring cups were to be ordered. She/he also verified that the detergent was not dispensed properly into the washing machine and that no gowns were accessible in the soiled linen room. During observation of the sorting of soiled linen in the Tea Olive Cottage on 4/30/13 at approximately 12:40 PM, CNA #1 was observed sorting linen with wrist length disposable gloves and no apron/gown. CNA #1 was observed using a paper cup to measure the detergent before dispensing into the laundry. The paper cup did not have any indication of how much detergent was being used. During an interview with CNA #1 s/he stated paper cups were used because there were no co… | 2017-01-01 |
| 7531 | 7531 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2013-05-01 | 514 | D | 0 | 1 | 9H2211 | **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 accurately record the administration of sliding scale insulin on the Medication Administration Record (MAR) for 1 of 3 residents reviewed for sliding scale insulin. (Resident #19) The findings included: Record Review revealed Resident #19 had a [DIAGNOSES REDACTED]. Review also revealed physician's orders [REDACTED]. A new physician order [REDACTED]. Additionally, there was a clarification order to use [MEDICATION NAME] Insulin for sliding scale coverage. The standing order procedure was for the following units of insulin to be administered based on the result of a fingerstick blood sugar (FSBS) result: FSBS: 0 - 199 - 0 units; 200 - 250 - 4 units; 251-300 6 units; 301 - 350 - 8 units; 351-400 10 units. Review of the MAR (Medication Administration Record) revealed that 2 units of [MEDICATION NAME]had been entered as having been administered on 4-17, 4-18, 4-19, 4-24, 4-25, 4-27 and 4-28-13. The dates represented all the dates when the Resident's FSBS was below 200 when the Resident was scheduled for FSBS at 4:30 PM. In an interview with LPN #2 on 5-1-13 at 9:45 AM, s/he was unable to explain why 2 units had been entered into the MAR. The Clinical Nurse Specialist was called by LPN #2. On 5-1-13 at 10:15 AM, s/he reviewed the record including the Physician Orders, the MAR and nursing notes. Nursing Notes attached to the MAR contained conflicting statements. The nurse note documented that no units of insulin had been administered but the note also stated that 2 units had been administered. The Clinical Nurse Specialist was unable to explain the entries and it appeared that the Resident received 2 units when none should have been administered. The Clinical Nurse also agreed the notes were confusing. The Director of Nursing stated sh/e had spoken with the nurse and that in order to enter the FSBS into the MAR the system required the nurse to enter a number of … | 2017-01-01 |
| 8622 | 8622 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 157 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey the facility failed to ensure one of 15 sampled resident's physician was notified of a change in condition. Resident #15 had a new onset of left ankle swelling and pain that was not reported to the physician for 6 days. The resident subsequently was diagnosed with [REDACTED]. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 5/1/12 the resident sustained [REDACTED]. The body audit revealed the resident moved all extremities, denied pain and was noted to have a skin tear to the right knee and a hematoma to the forehead. No other injuries were noted at that time. On 5/3/12 at 10:38 PM, .right ankle red area lateral side with 3+ [MEDICAL CONDITION], tender to touch and guarding with movement . The next note was dated 5/5/12 that documented: Noted slight discoloration to the left ankle and dark discoloration to the med (sic) section of the bottom of her left foot. She is able to move her foot on command. 1-2+ [MEDICAL CONDITION] to the left ankle. Will continue to monitor. On 5/9, L (left) ankle continues with +2 [MEDICAL CONDITION]. Warm to touch. ROM (Range of motion) appears intact to L ankle; elder non-cooperative with moving foot . The physician was contacted at 11:30 PM on 5/9/12. Review of the physician's orders [REDACTED]. On 5/11/12 an order was written to increase the [MEDICATION NAME] to four times daily, ice packs to the left ankle and an ace wrap. An orthopedic consult was waived per the family's request. Review of the X-Ray report signed by the Radiologist on 5/11/12 at 8:07 AM revealed the findings were soft tissue swelling is seen about the ankle, particularly laterally. The lateral view is technically poor due to summation artifact. AP and oblique suggest lucency coursing through the distal fibula. I cannot exclude a distal fibular fracture. During an interview on 6/18/12 at 3 PM, the Director of Nurs… | 2016-01-01 |
| 8623 | 8623 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 225 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, the facility failed to thoroughly investigate a reportable incident. Resident #15 sustained a fall on 5/1/12. On 5/10/12, a left distal fibular fracture was discovered. The facility failed to thoroughly investigate how the fracture occurred and failed to rule out a possible occurrence of abuse or neglect. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 5/1/12 the resident sustained [REDACTED]. The initial assessment revealed a skin tear to the right knee and a hematoma to the forehead. No other injuries were noted at that time. From 5/3/12 to 5/9/12 the resident exhibited swelling, pain and discoloration of the left foot/ankle. The physician was contacted at 11:30 PM on 5/9/12. Review of the X-Ray report signed by the Radiologist on 5/11/12 at 8:07 AM revealed the findings were .I cannot exclude a distal fibular fracture. Review of the Investigative File revealed the facility obtained only one statement related to the actual fall on 5/1/12. The Certified Nursing Assistant (CNA #1) was transporting the resident in her wheelchair when the resident's foot inadvertently was caught under the wheelchair and the resident toppled forward of the chair. The CNA acted appropriately before, during and after the incident. There was no indication on 5/1/12 that the resident injured her left ankle. Further review revealed no other staff statements were obtained between the 5/1/12 fall and the identification of the resident's fracture. The facility failed to thoroughly investigate how the fracture occurred and failed to rule out possible abuse or neglect related to the fracture. During an interview on 6/18/12 at 3 PM, the Interim Director of Nurses (IDON) stated that CNA #1's statement was the only statement obtained. She also confirmed that other staff were not interviewed regarding the fall, subsequent fracture and the facil… | 2016-01-01 |
| 8624 | 8624 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 226 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey based on record review, interview and review of the facility's policy on Abuse, the facility failed to ensure their policy was implemented related to investigation of neglect, and protection of residents. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 5/1/12 the resident sustained [REDACTED]. The initial assessment revealed a skin tear to the right knee and a hematoma to the forehead. No other injuries were noted at that time. From 5/3/12 to 5/9/12 the resident exhibited swelling, pain and discoloration of the left foot/ankle. The physician was contacted at 11:30 PM on 5/9/12. Review of the X-Ray report signed by the Radiologist on 5/11/12 at 8:07 AM revealed the findings were .I cannot exclude a distal fibular fracture. During an interview on 6/18/12 at 3 PM, the Interim Director of Nursing (IDON) stated that CNA #1's statement was the only statement obtained. She also confirmed that other staff were not interviewed regarding the fall/fracture and the facility did not investigate any possible occurrences between the time of fall and the discovery of the possible fracture. Review of the facility's policy on Abuse and Neglect revealed the following: All elder/family concerns/grievances and occurrences will be investigated and appropriately reported to the appropriate authorities. Events such as but not limited to falls .are investigated for possible abuse. Cross Refer to F 225 as it relates to the facility's failure to thoroughly investigate and report allegations of neglect. | 2016-01-01 |
| 8625 | 8625 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 241 | D | 0 | 1 | X5FK11 | **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 promote care in a manner that maintains or enhances each resident's dignity for 1 of 13 residents observed for dining. Staff failed to serve and feed Resident #4 in a timely manner during meal observations on 2 days of the survey. The findings included: The facility admitted Resident #4 on 5/22/10 with [DIAGNOSES REDACTED]. Review of the medical record on 6/18/12 revealed Resident #4 was in a geri chair when out of bed, was on a regular diet, and was dependent on staff for feeding. During observation of the dinner meal service on 6/18/12 at approximately 5:15 PM, Resident #4 was seated in her geri chair with three other residents at one of two tables in the dining area. Three residents were seated at the other dining table. Two staff members began to plate the residents' food and serve those seated at the tables. At approximately 5:30 PM, all of the residents seated at the two tables were served and eating except for Resident #4. At approximately 5:30 PM, one staff member was observed in the kitchen pouring a packet into a container, mixing liquid into the container, and placing the container into the microwave oven. The staff member stirred the contents of the container (bowl) and mixed in a small container of butter/margarine. The staff member then placed the bowl onto the table at Resident #4's place setting. At that time, the staff member proceeded to assist with plating and serving dinner to residents in their rooms along either hall. During this period of time, one Registered Nurse (RN) staff member was observed walking past the dining area several times without observing that Resident #4 had not been served and was not eating. At approximately 5:45 PM, one of the staff members sat beside Resident #4, told the resident she had some grits, and proceeded to feed the resident. During this meal observation, Resident #4 sat for 30 minutes at the table whil… | 2016-01-01 |
| 8626 | 8626 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 309 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey the facility failed to ensure one of 14 resident's received for the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being. Resident #15 sustained a fall from the wheelchair on 5/1/12 and an order was written for neuro (neurological) checks to be completed. The neuro checks were not completed as ordered. The resident subsequently was diagnosed with [REDACTED]. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 5/1/12 the resident sustained [REDACTED]. The body audit revealed the resident moved all extremities, denied pain and was noted to have a skin tear to the right knee and a hematoma to the forehead. The Physician was notified and the following order was obtained on 5/1/12 at 1:10 PM: Neuro checks every 15 minutes x 1 hour, every 30 minutes x 2 hours, every hour x 8 hours and every 8 hours x 1 day. Two days later on 5/3/12 the resident was noted to have ankle pain and swelling. The physician was not contacted until 5/9/12 at approximately 11:30 PM. The resident was diagnosed with [REDACTED]. Review of the Neuro Checklist dated 5/1/12 revealed the neuro checks were not completed as ordered. The first every 15 minute checks for one hour were completed as ordered. Then the resident had 3 of the 4 required 30 minute checks. However, no neuro checks were completed since 3:30 PM on 5/1/12. The neuro checks should have been completed through 5/3/12 in the early morning. Further review of the Neuro checks revealed part of the assessment included the ability to move all extremities, and the strength of all extremities. During an interview on 6/18/12 at 3 PM, the Interim Director of Nurses (IDON) confirmed the neuro checks were not completed per the physician's orders [REDACTED]. | 2016-01-01 |
| 8627 | 8627 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 322 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review,observation, interview, and the facility Policy and Procedure for Management and Use of Gastrostomy Tube, the nurse failed to provide appropriate treatment and services during the gastrostomy tube flush for Resident # 3. ( 1 of 2 sampled residents observed for gastrostomy tube flush.) The findings included: The facility admitted Resident # 3 on 5/23/12 with [DIAGNOSES REDACTED]. Record review on 6/19/12 revealed the resident had a gastrostomy tube with flushes ordered for 200ml (milliliters) of water to flush peg tube every 6 hours. At 11:30 AM on 6/19/12, LPN #1 (Licensed Practical Nurse) was observed performing a tube flush for Resident #3. The nurse entered the room without knocking. The resident was asleep and the nurse proceeded with the treatment. She did not close the door to the room and the blinds were partially open. The nurse was observed to wash her hands 3 times during the procedure. Each time after washing her hands, the nurse turned off the water with a paper towel and then dried her hands on the same paper towel. Prior to the procedure the nurse did not place a barrier under the gastrostomy tube. She did not measure the amount of water for the flush. The nurse poured the water directly into the syringe without clamping the tube, thus allowing the water to flow continuously. There was no accurate measurement of water that the resident received. After the flush, the nurse applied gloves to rinse the syringe and plunger, turned the water off with gloved hand and placed the plunger inside the syringe without drying, and placed the syringe/plunger into a plastic bag. The nurse then remove her gloves and exited the room. The nurse confirmed she always stored the syringe and plunger together in the plastic bag, and also confirmed she did not wash her hands after removing her gloves before exiting the room. The facility provided Policy and Procedure Guidelines stated: #1.Explain proced… | 2016-01-01 |
| 8628 | 8628 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 371 | E | 0 | 1 | X5FK11 | On the days of the survey, based on initial tour, random observations, and interviews, the facility did not store, prepare, distribute and serve food under sanitary conditions. Camellia Cottage had out of date oatmeal packets in use. Forsythia Cottage had Italian Dressing packets out of date. Magnolia Cottage had lemonade out of date. The Thermometer was not properly cleaned while taking food temperatures in the Camellia Cottage. The findings included: During initial tour on 6/18/12 at 1:50 PM, 17 oatmeal packets marked were observed stored in a glass container that was labelled use by June 6,2012. The products were accessible to residents in the Camellia Cottage. RN #2 (Registered Nurse) checked the jar and confirmed the label specified use by 6/6/12. She contacted the Dietary Supervisor who also confirmed that the labels were marked this way because the expiration dates were on the cartons the products were shipped in and not on the individual packets. Magnolia Cottage had 15 packets of Italian Dressing labeled use by 4/29/12. The Dietary Supervisor confirmed the date and stated, Those should have been removed in April. Magnolia Cottage also had two 1 gallon containers of lemonade in the refrigerator labeled 6/13/12. RN #1 (Registered Nurse) confirmed the label read 6/13/12. She stated that should be thrown out. During observation of food temps on 6/20/12 at 12:35 PM in Camellia Cottage, Cook #2 was observed to clean the thermometer 3 different times and then lay the thermometer down on the counter with the tip touching the wood counter each time prior to tempting a food. The cook also measured the temperature of the rice entree and then placed the thermometer into the pork roast without cleaning the thermometer between the two entrees. | 2016-01-01 |
| 8629 | 8629 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-06-20 | 514 | D | 0 | 1 | X5FK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the medical records for Residents # 5 and # 10 did not accurately reflect information related to allergies. ( 2 of 14 sampled residents reviewed for allergies.) The findings included: The facility admitted Resident # 10 on 5/25/12 with [DIAGNOSES REDACTED]. Record review on 6/19/12 revealed the medical record to be marked : allergic to [MEDICATION NAME], and [MEDICATION NAME]. The Cumulative physician's orders [REDACTED]. Medication Nurse #1 was asked , How would you know if a resident had an allergy? She stated, I would check the box on the MAR (Medication Administration Record) for allergies. The nurse demonstrated by clicking on the allergy box on this residents MAR. She stated, Nothing shows here so she does not have any allergies. RN #2 (Registered Nurse) reviewed the medical record and stated, The allergies were never entered on the physician's orders [REDACTED]. The facility admitted Resident #5 on 4/25/2007 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 6/19/12 at 9:00 AM, revealed that a red sticker on the inner cover of the chart stated the resident had no known allergies .(NKA. Resident #5's History and Physicals dated 11/21/11 and 11/9/10 both stated that the resident had NKA. Resident #5's monthly physician's orders [REDACTED]. At 10:10 AM on 6/19/12 the allergies listed were verified by Registered Nurse (RN) #3, the Minimum Data Set (MDS) Coordinator. RN #3 spoke with the pharmacy and stated they had no record of the resident having allergies and that the system had inserted the allergies on the wrong resident's chart. At 10:25 AM on 6/19/12, RN #4, ( shift manager) also verified the allergies were listed on the resident's chart. On 6/19/12 at 10:55 AM, RN #3 stated she had called the Physician's Office, verified that the resident did not have any allergies and presented a Telephone Order which stated No Known Allergies, Remove any allergies … | 2016-01-01 |
| 9290 | 9290 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-01-17 | 225 | D | 1 | 0 | WZUA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure residents were protected during an investigation, failed to conduct a thorough investigation and failed to report a potential incident of neglect. Resident #1's CNA (Certified Nursing Assistant) was suspended 5 days after the allegation of neglect. The allegation of neglect was not thoroughly investigated or reported to the State Certification Agency. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 12/14/2011 Registered Nurse (RN) Supervisor documented: "This Elder was found in the floor sitting upright with blood on head, face and on the floor. She did not make any noise the companion just happen to walk to the front of the common area and saw her on the floor. The laceration to the back of her head measured 1.5 cm superficial. Site was cleansed by Primary Nurse. Neuro checks started per policy. Corrective action: Place tab alert to Elder to be worn anytime she is out of bed." On 12/15/2011 at 3:21 AM, Licensed Practical Nurse (LPN) #1 documented, "Regarding 12/14/2011 at (8:05 PM), this nurse was called to this cottage from (another cottage) by the CNA, stating there had been a fall. Upon arriving, elder was sitting upright on her buttocks on the tile area at the back of the cottage. There was blood present on elder in multiple small pools on the floor. Upon assessment, elder was noted to be alert and upset about the blood present on her hands and her clothes. One injury on back of head present; 1.5 cm x 0.2 cm in width. Site is superficial. No other apparent injuries. Approximate amount of blood lost: 40 ml. Assisted elder to lie down on pillow. Called RN supervisor and assisted with complete assessment. ROM of all extremities unchanged as compared with elder's prior ability. Pupils equal and round. Elder responds to verbal stimuli. Cleansed [MED… | 2015-05-01 |
| 9291 | 9291 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-01-17 | 226 | D | 1 | 0 | WZUA11 | On the day of the complaint inspection based on record review, interview and review of the facility's policy on Abuse, the facility failed to assure their policy was implemented related to the investigation of neglect, and protection of residents. The findings included: The facility failed to thoroughly investigate an allegation of neglect for Resident #1 related to incontinent care. The facility also failed to suspend CNA #2 following the allegation of neglect. During an interview on 1/17/2012 at 5 PM, the Interim Director of Nurses confirmed CNA #2 was not suspended until 12/19/2011 (5 days after the incident) and was suspended for one day. The IDON also confirmed that the allegation of neglect related to incontinent care was not thoroughly investigated and stated that since everything was under CNA #1 nothing else was done. Review of the facility's policy on Abuse and Neglect revealed the following: "Any staff member implicated in an incident where they may have committed abuse or neglect of a guest/elder will be placed on suspension pending the outcome of an investigation." "All elder/family concerns/grievances and occurrences will be investigated and appropriately reported to the appropriate authorities. Events such as but not limited to falls ...are investigated for possible abuse." Cross Refer to F 225 as it relates to the facility's failure to protect residents, thoroughly investigate and report allegations of neglect. | 2015-05-01 |
| 9292 | 9292 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-01-17 | 280 | D | 1 | 0 | WZUA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview the facility failed to ensure 1 of 3 resident's care plans were updated with new and appropriate interventions after a fall with injury on 12/14/2011. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the CNA Care Plan revealed Resident #1 was to have a "bed alarm, matt, lo bed, seat belt, anti-tipper w/c." The resident was also to be "toileted and repositioned every two hours while in seat belt." Review of the Nursing Care Plan date 4/21/2011 revealed a problem area of "I need assistance for transfers and ambulation. I have a hx of falls." Approaches included: "I have been evaluated by PT (physical therapy) on 10/23/2011, I need extensive assist of 1 for transfers, I can ambulate short distances with my walker and 1 assist. High fall risk. Provide for my safety. Make sure my call light is within reach, my walking path is free of clutter and I'm wearing non skid foot wear. Provide bed alarm in bed and out and floor matt." The care plan was updated on 12/7/2011 to include "I use a Sara Lift for transfers and my safety devices include bed alarm in bed/chair, matt, low bed and alarming seat belt." The care plan had not been updated to reflect the residents fall on 12/14/2011 and no new interventions were included. Review of the Nurse's Notes revealed on 12/14/2011 the RN (registered nurse) Supervisor documented: "This Elder was found in the floor sitting upright with blood on head, face and on the floor. She did not make any noise the companion just happen to walk to the front of the common area and saw her on the floor. The laceration to the back of her head measured 1.5 cm superficial. Site was cleansed by Primary Nurse. Neuro checks started per policy. Corrective action: Place tab alert to Elder to be worn anytime she is out of bed." | 2015-05-01 |
| 9849 | 9849 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 164 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility policy entitled "Enteral Feeding via Gastrostomy Tube" dated 11.09.02, the facility failed to provide privacy for Resident #10 during two tube feeding flushes for 1 of 2 residents observed for privacy during tube feeding flushes. The findings included: Resident #10 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 5/16/11 at 4:00 PM, a tube feeding flush was attempted by the Licensed Practical Nurse (LPN) #4. The LPN did not close the door or the blinds in the window while checking residuals prior to starting tube feeding flush. On 5/17/11 at 12:10 PM, a tube feeding and tube feeding flush was conducted by the LPN #5. The LPN did not close the window blinds throughout the procedure. On 5/18/11 at 12:00 PM, an interview with the Director of Nursing (DON) was conducted. She stated that the expectation is that staff closes the door and the blinds during a tube feeding flush. Per review of the facility policy entitled "Enteral Feeding via Gastrostomy Tube" dated 11.09.02, which states "5. while maintaining privacy, expose the feeding tube." | 2014-10-01 |
| 9850 | 9850 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 241 | D | 0 | 1 | B6NE11 | On the days of the survey, based on observation and interview, the facility failed to maintain an environment that enhances each resident's dignity during dining in 2 of 12 cottages observed for dining. Staff was observed eating their meal while a resident waited to be served. Two CNA's (Certified Nursing Aide) were observed standing while feeding a resident. The findings included: On 5/17/11 at 11:55 AM, it was observed that a resident was reading a newspaper while two staff members sat on each side of the resident eating sandwiches. The resident was waiting to be served lunch. A random observation on 5/16/11 at 5:23 PM revealed a CNA (Certified Nursing Aide) standing while feeding a resident in the dining room of the Jasmine Cottage. The Resident was observed attempting to eat food from her plate with her fingers. The CNA remained standing and encouraged resident to use a spoon to eat. The CNA then picked up the resident's plate and continued to feed the resident while standing. A random observation on 5/18/11 at 9:30 AM revealed a CNA (Certified Nursing Aide) standing while feeding a resident in the resident's room. The resident was in bed with the bed in the highest position. The resident was observed attempting to feed himself with a spoon and the CNA stood by the resident bed using a different spoon to feed the resident. An interview on 5/18/11 at approximately 9:45 AM with CNA #7 revealed that she stood because she preferred to stand. The CNA further stated "I like standing, I cannot sit long". | 2014-10-01 |
| 9851 | 9851 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 248 | E | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, 5 of 14 sampled residents had no structured activities observed. (Residents #1, #4, #6, #8, and #13) Random observations of 10 of 12 cottages revealed structured activities per the posted Activity Calendar were not provided to residents during the days of the survey and 6 of 7 participants in the Group Interview voiced concerns related to the lack of activities. The findings included: During initial tour of Forsythia Cottage, on 5/16/11 at 11:37 AM, the Activities Calendar was noted to be at standing eye height level, printed on 8 1/2 by 11 inch paper and difficult to read from chair height. The facility admitted Resident #1 on 2/26/10 and readmitted her on 5/10/11. Her [DIAGNOSES REDACTED]. On 5/18/11 review of the 2/11/11 Life Enhancement Assessment for Resident #1 indicated that the resident was interested in playing Uno (a card game), enjoyed large and small groups and structured activities but needed encouragement. There was no documentation in the notes that card playing had been offered as an activity to this resident. Review of the Life Enhancement Notes revealed documentation of the residents limited participation in only 10 activities since the beginning of January. The facility admitted Resident #8 on 6/24/09 with [DIAGNOSES REDACTED]. On 5/18/11 review of the 9/13/10 Life Enhancement Assessment for Resident #8 indicated that the resident was comfortable in large and small groups and with 1 on 1 sensory activities. Activity Interests and Preferences indicated that the resident needed encouragement and Participation Patterns indicated that she was a passive participant with activities. During the days of the survey, Resident # 1 and # 8 were not observed engaged in any structured activities. Both were observed in their room or in the day area with the television playing. Both resident's engaged in conversation with other residents and self propelled their wheel chairs throughout the cottage. There was no s… | 2014-10-01 |
| 9852 | 9852 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 366 | F | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the facility menus, the facility failed to make residents aware and provide substitutes at meals with similar nutritive value for residents that refused food. Resident #4 expressed concerns about alternate foods being available at meals. Resident #12 was not provided an acceptable alternate meal when she refused the vegetables offered. Six of seven residents during group expressed concerns regarding alternates being available at meals. The findings included: Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An interview was conducted with Resident #4 on 5/16/11 at 3:30 PM. The resident stated that during meals only an alternate meat is offered. She stated that if she does not want the meal offered she can get peanut butter crackers or a milk shake. She stated that no other alternates are provided. On 5/16/11 at 5:05 PM, an interview with the Food Service Director was conducted. He stated that a meat alternative is offered at each meal. He stated that they to have canned vegetables in stock and can microwave if they know a resident does not like a particular food prior to the meal based on the residents likes or dislikes. He stated that an alternate vegetable is not available on the steam table at meals. He stated that each kitchen has bread, peanut butter, jelly, and pimento cheese. The facility admitted Resident #12 on 12/18/09 with [DIAGNOSES REDACTED]. Record review revealed a care plan last reviewed on 5/03/11 that indicated the resident was to receive vegetables or organic foods and that she had a problem with milk (dairy). An observation on 5/17/11 at 12: 20 PM revealed the lunch provided was pork loin or chicken, green peas casserole or carrots and a roll. Resident #12 requested the pork lion and stated she did not want the carrots. CNA (Certified Nursing Aide) #7 informed the resident that cheese (dairy) was in the pea casserole and… | 2014-10-01 |
| 9853 | 9853 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 371 | F | 0 | 1 | B6NE11 | On the days of the survey, based on observation, interview, and review of the policies entitled "Reheating Food to Serving Temperature", "Kitchen Set-Up for Preparation and Production", and "Preventing Contamination of Food during Preparation and Serving", the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The findings included: On 5/16/11 at 10:35 AM, a tour of all the Cottage kitchens was conducted with the Food Service Director. In the Jasmine Cottage it was observed that a plastic bag with pancakes was not labeled or dated. The microwave contained rust on the inside of the door and in the inside back corners. The small refrigerator contained a cup with a thickened liquid that was not labeled or dated. In the Camellia Cottage it was observed that the microwave had rust on the inside of the door. The ice machine contained a pink substance around the screws on the top inside the ice machine and a rust colored substance on the metal in the back of the ice machine. In the Dogwood Cottage it was observed that a bag of fries in the freezer had slits in the bag. There was a pan on the counter covered with foil containing a pork loin. The microwave contained rust on the inside door and the paint of the inside top was bubbled up. In the Azalea Cottage it was observed that a container of sausage in the freezer was not labeled or dated. The microwave contained rust on the inside of the door and on the inside rim. In the Forsythia Cottage it was observed that the microwave had rust on the inside door and on the inside rim. One of the plastic lids on the steam table was broken and had a crack in the front. The reach in freezer in the dry storage area had ice build up on the bottom shelf of the freezer with boxes placed on top of the ice. In the Rose Cottage, an open bag with frosting was observed in the reach in refrigerator. The microwave had rust on the inside door. Both ovens contained dried food on the doors. The Food Service Director stated that neither oven had been used that… | 2014-10-01 |
| 9854 | 9854 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 249 | E | 0 | 1 | B6NE11 | On the days of the survey, based observations and interview, the facility failed to ensure that the Activity Director implemented and monitored the provisions of the activity program for residents to assure that was on-going and met the needs of the residents. The findings included: An interview on 5/18/11 at approximately 10:30 AM with Activity Director (AD) and the facility's Administrator revealed the facility attempts to have weekly worship services at the cottages. The AD stated trying to maintain a program of activities has always been difficult at the cottages. The AD further stated the CNAs (Certified Nursing Aides) in each cottage had the responsibility of providing a program of activities. The surveyor asked the AD when was the last time an in-service was provided to the CNAs related to structured program of activities in the cottages? The AD stated the last in-service was provided at the end of 2009 and the early part 2010. The AD was asked if she had been able to monitor the program of activities in the cottages to determine if they were being provided. The AD stated "no". The AD further stated she did not have anyone to assist her in providing a ongoing activity program in each cottage. The AD was asked about the posted "Sleepy Tea" activity that was to occur every day at 7 PM. The AD stated the "Sleepy Tea" was when the staff would give the residents tea to "help them from being anxious". The AD stated it was like to "study" to seem if it would calm the residents down. The AD stated the activities in each cottage were the same. The AD stated games, cards and books are provided for the residents. However, based on repeated observations on the days of the survey, there were no structured activities observed to be in place. | 2014-10-01 |
| 9855 | 9855 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 328 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure that a resident using an oxygen concentrator received proper treatment and care. The filters on both sides of the oxygen concentrator were not clean. (1 of 3 residents observed with oxygen concentrators) The findings included: Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. On 5/16/11 at 10:40 AM, during initial tour of the Magnolia Cottage, Resident #17 was observed receiving oxygen via a nasal cannula and plastic tubing which was connected to an oxygen concentrator. The oxygen concentrator had an air filter on the right and left sides of the machine. Both filters were observed to have heavy dust buildup which easily became airborne when scraped with a fingernail. Additional observations on 5/16/11 at 6:23 PM, 5/17/11 at 3:29 PM and 5/18/11 at 8:55 AM revealed both filters in the same condition. On 5/18/11 at 9:51 AM, during an and interview and observation with the Director of Nursing (DON), the DON agreed that the filters were heavily soiled with dust and needed to be cleaned. She stated that she would have to check the cleaning schedule and would "get back with me on that". On 5/18/11 at 11:15 AM, the DON stated that Clinical Engineering from Greenville Memorial Hospital services the oxygen concentrators and that the person she spoke to apologized for not cleaning the filters on that machine when he serviced the other concentrators earlier this month. | 2014-10-01 |
| 9856 | 9856 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 152 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on interviews and record reviews, the facility failed to obtain two Physician's signatures for statements of competency in accordance with state law in the Health Care Consent Act of South Carolina for 2 of 14 residents reviewed. The findings included: The facility admitted Resident #1 on 2/26/10 and readmitted her on 5/10/11. Her [DIAGNOSES REDACTED]. Record Review on 5/16/10 at 3:50 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated September 10, 2010. Review of the resident's MDS (Minimal Data Set) dated 3/2/10 revealed she had short and long term memory problems and required cueing for decision making. Review of the 2/10/11 MDS revealed a BIMS (Brief Interview for Mental Status) score of 6, indicating severely impaired cognition. The facility admitted Resident #8 on 6/24/09 with [DIAGNOSES REDACTED]. Record review on 5/16/11 at 2:35 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated 12/16/10. Review of the 9/14/10 annual MDS revealed she had short and long term memory problems and required assistance for decision making. Review of the 3/10/11 MDS revealed a BIMS score of 7, severely impaired cognition. During an interview at 3:30 PM on 5/17/11, the Social Services Supervisor stated that the Physicians rely on the the Social Workers to assist with resident's cognitive assessment to determine competency. She further stated that the Social Workers rely on the Physicians to sign the competency certificates. She confirmed that the Physician Certificate Ability or Inability to Consent to Admission or treatment for [REDACTED]. In addition, the Social Services Supervisor confirmed that the facility had no process in place to ensure that the competency certificates were signed by two physicians. Review of the South Carolina Code of Laws, Ch… | 2014-10-01 |
| 9857 | 9857 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 280 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, the facility failed to review/ revise the care plan for Resident #8 related to exit seeking behaviors, elopement and the placement of a Roam Alert bracelet. (1 of 5 residents reviewed for revision of the plan of care related to exit seeking/ Roam Alerts.) The findings included: The facility admitted Resident #8 on 2/26/10 and current [DIAGNOSES REDACTED]. On 5/17/11 at 9:50 AM, review of the Social Services Notes revealed the resident had eloped on 3/16/11 and that the resident had exhibited exit seeking behaviors on 2/21/11. A physician's orders [REDACTED]. Further review revealed that during the investigation of the elopement, staff reported that the resident did "exhibit intermittent exit-seeking behaviros (sic.) of kicking at the doors and pushing at the doors stating that she wants to go out." The Social Services Notes also revealed a note dated 2/11/11 revealing the resident also had a history of [REDACTED]. At 10:03 AM on 5/17/11, review of the Nurses Notes revealed a note dated 3/5/11 at 10:58 PM that stated the resident "used repetitive statements through evening and did exit seek." Another Nurses Note dated 2/21/11 at 11:13 AM revealed the resident wanted "to visit mother and go home. Banging on doors and kicking doors saying that she is a prisoner." On 5/17/11, review of the computerized and hard copy care plan revealed there was no care plan addressing the resident's behaviors, exit seeking, elopement or placement of the Roam Alert. During an interview on 5/18/11 at 11:45 AM, the Director of Nursing confirmed that the care plan did not address the resident's exit seeking behaviors, the placement of the Roam Alert bracelet or elopement risk. During an interview on 5/18/11 at 12:20 PM, RN #4, MDS (Minimal Data Set) Coordinator stated she was unaware of the resident's exit seeking behaviors or elopement. | 2014-10-01 |
| 9858 | 9858 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 323 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Survey, the facility failed to provide adequate supervision to prevent The facility failed to minimize the risk for accidents by failing to stabilize the oxygen cannister for Resident #2 ( 1 of 3 residents observed with oxygen.) Resident # 13, a known fall risk, was observed to be left unattended in the bathroom. ( 1 of 6 residents reviewed for falls) The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. On 5-16-11 at 3:00 PM review of the resident's records revealed a history of falls on 5-7-10, 5-24-10, 9-11-10, 9-12-11, 11-7-10, 3-26-11, and 4-5-11. Further review revealed a physician's orders [REDACTED]." The 4/30/11 Care Plan approaches included use of a "Pressure pad alarm in wchair (wheel chair) as safety devise (sic.)" for a noted problem of "I need reminders to call for assist with transfers (Parkinson's, Dementia, Debility). I have hand tremors, lean forward in my wchair & arthritis pain. I want to maintain my independence so may not use my call light for assist. I tire in the eve. (evening) & lack safety awareness. Hx (history) falls." It was observed on 5-17-11 at 10:45 AM that Resident #13 was left unattended on the toilet in the bathroom while (CNA) #6 was in the day room. During multiple observations (on 05/16/2011 at 10:40 AM, 2:30 PM, 3:30 PM, and 5:45 PM; on 05/17/2011 at 9:00 AM and 3:25 PM; and on 05/18/2011 at 8:55 AM, 9:05 AM, and 10:55 AM), an unsecured oxygen (E) tank was noted on the floor at the head of Resident #2's bed. During an interview on 05/17/2011 at 4:10 PM, Licensed Practical Nurse (LPN) #6 verified that the oxygen tank was unsecured. On 05/18/2011 at 9:05 AM, Certified Nursing Aide #6 verified that the oxygen tank was on the floor and had never been in a stabilizer. No intervention was implemented until, on 05/18/2011 at 10:50 AM, LPN #1 again verified that the oxygen tank was unsecured and placed it in a stabilizer. Review of the facility Respira… | 2014-10-01 |
| 9859 | 9859 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 322 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of the facility policy entitled "Standard Infection Precautions", the facility failed to provide Resident #10 with a bolus feeding appropriate to prevent contamination of feeding in 1 of 2 residents observed for tube feeding flushes. The findings included: Resident #10 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 5/17/11 at 12:10 PM, a tube feeding and tube feeding flush was conducted by LPN #5. The LPN dropped the syringe onto the floor. She picked up the syringe with her gloved hand and went into the bathroom to rinse the syringe in the sink. The LPN returned to the resident to continue with placing formula into the syringe. The LPN did not change her gloves nor wash her hands before returning to continue with the tube feeding flush. Per review of the facility policy entitled " Standard Infection Precautions" dated 20.06.01, which stated... "change gloves between tasks and procedures on the same elder and after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another elder. Clean hands each time gloves are removed". | 2014-10-01 |
| 9860 | 9860 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 274 | D | 0 | 1 | B6NE11 | **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 identify significant physiological changes and complete significant change assessments for one of fourteen residents reviewed for Minimum Data Set (MDS) accuracy. Resident #13 had noted declines in activities of daily living (ADL) functions and no significant status change assessments were completed. The finding included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-17-11 at 11:30 am revealed the annual MDS assessment completed on 4-28-10 showed that a significant change assessment should have been completed on 7-22-10 based on data obtained under Section G of the assessment document, when compared to the quarterly MDS assessment completed on 7-22-10. Significant changes (declines) were noted on 4-28-11 in bed mobility which was coded "0" or "independent", compared to 7-22-10, which was coded as "3" or "extensive assistance". Also the resident's ability to transfer on 4-28-11 was coded "0" or "independent" compared to "3" or "extensive assistance" on 7-22-10. The quarterly MDS completed on 7-22-10 revealed a significant change assessment should have been completed on 10-13-10 based on data obtained under Section G of the assessment document, compared to the quarterly MDS completed on 10-13-10. Significant changes were noted on the 7-22-10 assessment in dressing which was coded as "2" or "limited assistance", compared to "3" or "extensive assistance" on 10-13-10. A decline was noted on 10-13-10 in toilet use from 7-22-10, which was coded as "2" or "limited assistance", compared to "3" or "extensive assistance" on 10-13-10. The quarterly MDS completed on 10-13-10 revealed a significant change assessment should have been completed on 1-10-11 based on data obtained under Section G of the assessment document, compared to the quarterly MDS completed on 1-10-11. Significant changes were as follows: the 10-13-10 MDS… | 2014-10-01 |
| 9861 | 9861 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 282 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and observations, the facility failed to follow care plan directives to monitor the use of chair safety alarms for one of six residents reviewed for alarm implementation. Resident #13's Care Plan for use of a pressure pad alarm was not followed. The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-16-11 at 3:00 PM revealed that the 4/30/11 Care Plan approaches included "Pressure pad alarm in wchair (wheel chair) as safety devise (sic.)", for a noted problem of "I need reminders to call for assist with transfers ([MEDICAL CONDITION], Dementia, Debility). I have hand tremors, lean forward in my wchair & arthritis pain. I want to maintain my independence so may not use my call light for assist. I tire in the eve. (evening) & lack safety awareness. Hx (history) falls." Further review revealed a physician's orders [REDACTED]." On 5-16-11 at 10:45 AM during the Initial Tour with Certified Nursing Assistant (CNA) #4, Resident #13 was observed with the pressure pad alarm in place, but it was turned off as indicated by the switch in the "off" position. During an interview at this time, CNA #4 was asked about the need for the pressure pad alarm and identified that it was turned off. She stated that Resident #13 had a history of [REDACTED]. On 5-16-11 at 5 PM, Resident #13 was observed in the dining area with other residents. No staff members were in attendance and the resident's alarm was again in the "off" position. | 2014-10-01 |
| 9862 | 9862 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 309 | D | 0 | 1 | B6NE11 | **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 services as ordered by the physician for one of fourteen sampled residents reviewed for care and services. The facility failed to perform weekly weights as ordered for Resident #2. The findings included: The facility admitted Resident #2 on 03/10/2011 with [DIAGNOSES REDACTED]. Record review on 05/16/2011 at 4:15 PM revealed a physician's orders [REDACTED]. Further review revealed no weekly weights were recorded. During an interview on 05/18/2011 at 10:00 AM, Licensed Practical Nurse (LPN) #1 verified the physician's orders [REDACTED]." Review of the summaries revealed no reference to weights. During an interview on 05/18/2011 at 12:20 PM, LPN #1 stated, "Dietary keeps up with the weekly weights and they never bring them back so that is why we have no record of the weekly weights." During an interview on 05/18/2011 at 1:05 PM, the Director of Nutritional Services, accompanied by the Director of Food Services, stated, "We did not do weekly weights." | 2014-10-01 |
| 9863 | 9863 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 367 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, and interviews, the facility failed to provide the diet as ordered by the physician for one of the three sampled residents reviewed for mechanically-altered diets. Resident #13 was provided solid foods on a mechanically-altered diet. The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-16-11 at 3:00 PM revealed physician's orders [REDACTED]." Also, in the 4-30-11 Care Plan, the resident's problem stated: "I eat a regular diet with my meat and other foods cut into small pieces because it's had (sic.) for me to chew some foods. I'm (sic.) might get constipation." The Approaches included: "Make sure I get the diet right". Record review also revealed that the resident was evaluated by Speech Therapy and treated for [REDACTED]. The Speech Therapy Treatment Plan discharge summary on 12-9-10 revealed an order for [REDACTED]. Diet modification-Res. (Resident) to tolerate least restrictive diet consistency w/o (without) s/s (signs or symptoms) aspiration: Res. able to return to regular diet consistency. Staff instructed to cut food into small pieces." On 5-16-11 at the 5:00 PM meal observation, Resident #13 was served a fish sandwich and french fries. The resident's meal was not chopped into small pieces. The resident stated, "Sometimes I get help eating", and "Sometimes they make my food into smaller pieces." It was observed that the resident struggled with cutting the fish sandwich and eventually removed the fish from the bun and ate it with her hand. She placed large pieces in her mouth, and after being unable to handle them, removed them and placed them back onto the plate. On 5-16-11 at 5:40 PM, a note was observed above the resident's bed instructing staff to chop food into small pieces and assist with all meals. | 2014-10-01 |
| 9977 | 9977 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-04-07 | 157 | D | 1 | 0 | O72D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observations, record review and interviews, the facility failed to notify the family in a timely manner for Residents #1 who had a red skin irritation noted to the perineal and anal area. The findings included: The facility admitted Resident #1 on 12/08/2006 with [DIAGNOSES REDACTED]. Review of an Incident Investigation dated 03/12/2011 stated, "Elder has bright red skin irritation noted to the perineal and anal area. ...5 cm (centimeter) area noted to R (right) groin area from brief irritation. Two small spots noted to be opened near anal area. Protective cream applied... Emailed...for order for Xanaderm, will continue to monitor." Review of the Departmental Notes (nurse's notes) on 04/07/2011 at approximately 9:30 PM revealed an entry on 03/04/2011 the next entry dated 03/14/2011 stated, "Perineal [MEDICAL CONDITION] noted. Assisted back to bed skin cleansed and Aloe Vista applied... Observe closely." There was no entry for the 03/12/2011 assessment that resulted in the Incident Investigation and no mention of family notification. Review of the 24 Hour Report for 03/12/2011 showed no documentation regarding the skin irritation or concerns related to Resident #1. There was no evidence in the medical record that the family was notified at all, of the change in the resident's skin. During an interview with the surveyor on 04/07/2011 at 9:45 PM, Registered Nurse (RN) Supervisor #1 stated there was no Departmental Notes related to the change in Resident #1's skin and the information was not included on the 24 Hour Report for 03/12/2011. Observation of perineal care for Resident #1 on 04/07/2011 at approximately 10:20 PM revealed no open areas on the anal or perineal skin. | 2014-08-01 |
| 10073 | 10073 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-02-14 | 225 | E | 1 | 0 | TWHZ11 | **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 reportable incidents, the facility failed to assure each reportable incident was reported within the mandated timeframes and to the appropriate agencies. Resident #1's injuries of unknown origin were not originally reported to the state certification agency until 3 days after the incident occurred (12/22/2010) and the 5 day follow up was not reported until 1/28/2011. Another injury of unknown origin occurred on 1/28/2011 that was not reported to the state certification agency. A random resident had a fracture that occurred during a transfer that was neither reported to the state certification agency nor thoroughly investigated. Another random resident with an allegation of verbal and physical abuse did not have the 5 day follow up reported to certification within the 5 days. One of three residents reviewed for injuries of unknown origin and 2 random reportable incidents. The findings included: The facility admitted Resident #1 on 1/6/2010 with diagnosed including: [DIAGNOSES REDACTED]. Review of the nursing notes revealed the following entries: "11/18 2 bruises notes to upper extremities ... ...left upper extremity with a silver dollar sized bruise, unopened and not draining, bruise is with a purplish hue ... ...second bruise noted to right upper extremity dime sized ... ...elder had been combative during am care ... ...am care performed without the aid of PRN [MEDICATION NAME]. " "12/14 CNA found quarter sized skin tear on posterior right arm this am. Origin unknown." "12/16 Bruise to left upper posterior arm and right forearm ... ...also noted bruise under chin will continue to monitor and report. " "12/19 2:43 AM, elder has bruises to right and left arms, skin tear on right posterior upper arm, no combative behavior noted today, Urine for lab obtained." "12/19 3:02 AM, 3 small circular bruises noted on elder's left anterior upper arm at a… | 2014-06-01 |
| 10074 | 10074 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-02-14 | 323 | E | 1 | 0 | TWHZ11 | **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 policy on abuse and neglect and transfers, the facility failed to ensure Resident #1 was transferred in a safe and appropriate manner. Resident #1 was assessed as requiring the assistance of a stand up lift per the Certified Nursing Aide Care Plan. The Certified Nursing Aides who routinely cared for the resident failed to follow the recommendations, failed to utilize the appropriate devices during a transfer and failed to use the appropriate technique to transfer Resident #1. Resident #1 sustained multiple injuries of unknown origin. One of three residents reviewed for injuries of unknown origin. The findings included: The facility admitted Resident #1 on 1/6/2010 with diagnosed including: [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 was unable to complete the mental status interviews and was coded as having short and long term memory problems and was severely impaired in the ability to make daily decisions. Resident #1 was also coded as having resisted care, physically abusive and other behaviors occurring 1-3 times during the assessment period. Resident #1 was also coded as needing extensive one person assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, hygiene and bathing. The resident was also coded as needing limited one person assistance with eating. Resident #1 was assessed as needing a wheelchair and had bilateral range of motion impairments of her lower extremities. Review of Resident #1's care plan revealed a problem area of cognitive loss with an approach to "gently redirect me when I become angry or combative. If I don't respond to redirection, leave me alone for a little while." Another problem area of assist with transfers was identified which was updated on 1/4/2011 with approaches including no enabler bars (side rails), Geri-sleeves and elbow protect… | 2014-06-01 |
| 31 | 31 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2020-01-29 | 759 | D | 1 | 1 | J64I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse(LPN) #1 on 1/28/20 at 12:10 PM revealed s/he crushed [MEDICATION NAME]/[MEDICATION NAME] 25/100 milligrams(mgs) and [MEDICATION NAME] [AGE] mg and placed each in the same cup. After entering Resident #118B's room, LPN #1 placed 30 cubic centimeters(cc) of water into each of two 30cc medication cups. LPN #1 placed approximately 10 cc of water from one of the medication cups containing water into the medicine cup containing the crushed medications. After checking and confirming placement of the [MEDEQUIP] tube([DEVICE]), LPN #1 placed approximately 20 cc of water into the [DEVICE]. Medications were placed in the [DEVICE], residual medication was observed and LPN #1 placed water from the second medication cup twice trying to administer all of the medication. During this time, a small amount of spillage was noted dripping off of LPN #1's glove. S/he placed the remaining water into the tube. Observation of the medication cup which contained the medications revealed medication was still in the bottom of the cup. LPN #1 confirmed the medication in the cup. LPN #1 stated s/he should have probably let the medicine sit a little longer to help the medications dissolve. Review of the facility policy titled Enteral Tube Medication Administration revealed the policy did not address residual medication. | 2020-09-01 |
| 32 | 32 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 159 | B | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to to inform residents of balances in their personal funds for 2 of 12 residents interviewed.(Resident #48 & #46) The findings included: Record review of the Minimum Data Set(MDS) on 7/24/17 revealed Resident #48 had a Quarterly MDS dated [DATE] which listed the resident as having a 12 on the Brief Interview for Mental Status(BIMS). During an interview on 7/24/17 with Resident #48, he/she stated the facility did not inform him/her of the amount of money in his//her personal account. Record review of the MDS on 7/24/17 revealed Resident #46 had a Quarterly MDS dated [DATE] which listed the resident as having a 15 on the BIMS. During an interview on 7/24/17 with Resident #46, he/she stated the facility did not inform him/her of the amount of money in his/her personal account. During an interview with the Business Office Manager on 7/26/17 at 2:30 PM, he/she confirmed only a statement goes to the responsible party and not the resident. Information provided by the facility related to personal funds on 7/26/17 at 3:05 PM states the following: .A summary of activity is made available upon request and at least quarterly to each resident or resident representative . No additional information was presented as how the resident's knew they could request the balance of their personal account. | 2020-09-01 |
| 33 | 33 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 281 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F333 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physician's order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. (cross reference F333 and F425) On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) and multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-… | 2020-09-01 |
| 34 | 34 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 333 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Physician order dated 1/27/12 (date of admission) listed [MEDICATION NAME] as an allergy. -Physician order dated 6/11/12 stated D/C (discontinue) [MEDICATION NAME] -Physicians order dated 8/23/12 stated [MEDICATION NAME] ung (ointment) sig (give) instill inside lower eye lids ou (both eyes) q PM (every evening) x 7 days and then use PRN (as needed) for itching. - MAR (medication administration record) review January- December, 2012 showed approximately 61 scheduled plus PRN doses of [MEDICATION NAME] Ophthalmic Ointment had been administered -Physician order dated 6/3/13 stated Add allergy to [MEDICATION NAME] and tenoretic. -MAR review [REDACTED]. -January - September, 2013 MAR indicated [REDACTED]. -Physician order dated 9/17/13 stated change [MEDICATION NAME] Oint (ointment) to q hs (every bedtime) -MAR review [REDACTED]. -MAR review [REDACTED]. -MAR review [REDACTED]. -Consultant Pharmacist Report dated… | 2020-09-01 |
| 35 | 35 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 371 | E | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to ensure the cooktop was clean and free of grease build up, no dented cans in storage, the blades on the Buffalo Chopper and the Robo-coupe were free of dents and hazards, labeling and dating of raw chicken in the coolers and open packages of cookies, resident's food, use of pasteurized shell eggs, safe and clean storage ice in ice machines, removal of expired food in nutrition center refrigerator, clean and sanitary storage areas in nourishment center in 1 of 1 kitchen and 2 of 2 nourishment areas. The findings included: During initial tour on 7/23/17 at 10:45 AM, inside the walk-in refrigerator, a pan of cake covered with parchment paper and was not labeled or dated. The Assistant Dietary Manager said The cake is for lunch today. A can of pudding was also observed in the refrigerator with the lid partially cut open and still attached to the can and was not labeled or dated. Observed and verified by the Assistant Dietary Manager and the CDM was a larger plastic container which contained 3 whole chickens, and a bag of assorted chicken parts, which were not labeled or dated. Additionally, observed 1 Case of eggs in the shell from Glenview Farms, there was no indication on the box label and, the eggs did not have the stamp indicating that the eggs were pasteurized. The Assistant Dietary Manager and the CDM said the eggs are used for entrees and boiled eggs for the residents and h/she will check and see if the eggs are pasteurized. On 7/25/2017, the CDM provided a copy of the new product h/she will be ordering from foodservice vendor, to ensure that pasteurized eggs are used for the residents, Davidson's Pasteurized Eggs. The Policy and Procedures, Labeling and Dating, states, It is the Policy in the Dietary Department that all items upon delivery to storage area and freezer are labeled and dated. During initial tour on 7/23/2017 at approximately 11:00 AM of the dry storage room, observed 1 dented can of beets stored on th… | 2020-09-01 |
| 36 | 36 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 425 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Pharmacy failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F333) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). Neomycin and Polymyxin are common ingredients in both Maxitrol and Neosporin. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving Maxitrol for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to Neosporin (Neomycin-Bacitracin-Polymyxin) and multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to which Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). The Consultant Pharmacist verified in an interview on 7/25/17 at approximately 12:0… | 2020-09-01 |
| 37 | 37 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 431 | D | 0 | 1 | LLSR11 | Based on observations, record reviews and interviews the facility failed to assure that sterile medications were properly stored in 1 of 4 medication carts and 1 of 2 treatment carts and that medications were securely stored on 1 of 4 medication carts. The findings include: On 7/23/17 at approximately 11:39 AM the medication cart # 2 on the North Unit was observed to be unattended and unlocked for approximately 6 minutes and one wandering resident in a wheelchair was touching and pulling on the cart. LPN (Licensed Practical Nurse) # 1 was informed of the observations on 7/23/17 at approximately 11:46 AM and he/she verified that the cart was had been left unlocked, unattended and that a wandering resident was in the area. On 7/23/17 at approximately 11:49 AM inspection of the top right hand drawer of medication cart # 2 on the North Unit revealed one opened bottle of Normal Saline USP (United States Pharmacopoeia) 100 ml (milliliter) by McKesson Lot # 20 which had been dated by the facility as opened on 7/21/17. The manufacturers label stated Single Patient Use, Sterile, 0.9% (percent) Sodium Chloride and contained about 80 ml. This finding was verified by LPN # 1 on 7/23/17 at approximately 11:53 AM. An observation on 7/25/2017 at approximately 10:50 AM, during wound care, revealed a 100 mg (milligram) bottle of Sterile Normal Saline-Single Use manufactured by McKesson with Lot # 10 with expiration date 5/11/2019 was opened and left on 1 of 2 treatment carts with other medications for resident use. After opened, the Sterile Normal Saline is no longer sterile. During an interview on 7/25/2017 at approximately 10:55 AM the Assistant Director of Nursing verified the findings and removed the bottle of Normal Saline from the treatment cart. | 2020-09-01 |
| 38 | 38 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 456 | D | 1 | 1 | LLSR11 | > Based on observations, interviews, and review of the facility policy titled, Description of Dryers, and Equipment Care, the facility failed to ensure a large build-up of lint was removed from the backs and upper sides of the lint traps in 2 of 6 clothes dryers. The four other clothes dryers were in use and the lint traps were not observed at this time. The findings included: An observation on 7/25/2017 at approximately 8:30 AM revealed 2 of 6 clothes dryers with a large build-up of lint in the backs and upper side in 2 of 6 clothes dryers. Four other clothes dryers were in use at this time and the lint traps were not observed. An interview on 7/25/2017 at approximately 8:30 AM with the Housekeeping Supervisor confirmed the findings and provided a copy of the facility policy titled, Description of Dryers, and Equipment Care. The policy titled, Description of Dryers, states, These lint screens MUST be brushed and cleaned every 2 loads. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation -- one spark on lint can cause a fire. Review on 7/25/2017 at approximately 8:38 AM of the facility policy titled, Equipment Care, states, The equipment in the laundry consists of washing machines and dryers. These items need daily maintenance from laundry personnel and should have preventive maintenance performed by the maintenance department. It is your responsibility to see that the equipment is loaded and operated properly, and to be sure that the staff sets up an effective schedule to clean the lint filters on the dryers every two hours to save energy and to prevent fires. Review on 7/25/2017 at approximately 8:45 AM of a form titled, Lint Trap Schedule, for July 2017 was initialed by a laundry worker that the lint was removed at 8:00 AM on 7/25/2017, but 2 of 6 clothes dryers contained a large build-up of lint. Review on 7/25/2017 at approximately 10:15 AM of a form titled, Wee… | 2020-09-01 |
| 39 | 39 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 567 | E | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that written authorization was obtained prior to disbursing monies from the account of one of one sampled resident reviewed for personal funds (Resident #23). The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. During an interview and review of the personal funds account with the Resident Financial Coordinator on 10/11/18 at 2:27 PM, multiple deductions (7/12/18, 7/31/18, 8/9/18, 8/24/18, and 9/7/18) were noted for the Beauty Shop for Resident #23. The invoices for the services provided were reviewed but no written authorizations were obtained from the resident/resident representative to deduct monies from the personal funds account. | 2020-09-01 |
| 40 | 40 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 568 | D | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that quarterly statements were provided to Resident #23, one of one sampled resident reviewed for personal funds. The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. The resident stated,My daughter might. Review of the 7/15/18 Significant Change in Status Assessment revealed the resident had a had a Brief Interview for Mental Status (BIMS) score of 15 indicating s/he was cognitively intact. During an interview on 10/11/18 at 2:27 PM, the Resident Financial Coordinator provided the last quarterly statement for Resident #23 for review. The Resident Financial Coordinator confirmed that the statement had been sent to the resident's daughter instead of to the resident. | 2020-09-01 |
| 41 | 41 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 607 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop and/or implement abuse reporting and investigation policies for 2 of 4 sampled residents reviewed for abuse/injuries of unknown origin. An allegation of abuse was not reported timely or thoroughly investigated for Resident #42. The finding included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was aware of the 2 hour reporting requirements for allegations of abuse. S/he stated that s/he was not made aware of the allegation until 8/15/18. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the… | 2020-09-01 |
| 42 | 42 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 609 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to report allegations timely to the State Agency for 2 of 2 allegations/incidents reviewed. Resident #42 had an allegation of physical and verbal abuse that was not reported to the state agency within the required timeframes. The facility failed to report an injury of unknown origin with major injury timely for Resident #37. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was… | 2020-09-01 |
| 43 | 43 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 610 | E | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that CNA #1 was suspended during the investigation. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the RN Supervisor, and 4 of the 5 CNAs on duty on the 100 Hall, including the alleged perpetrator. There were no statements from the two nurses on duty on the 100 Hall. All statements were either unwitnessed or witnessed by one individual. During an interview on 10/11/18 at 12:45 PM, when asked to describe a thorough investigation, the DON stated, You should talk to the res… | 2020-09-01 |
| 44 | 44 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 623 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident #22, #19, # 57, #47 and #100 as soon as practicable of a facility initiated transfer. 5 of 5 reviewed for transfer to the hospital. The findings included: The facility admitted Resident #22 on 7/12/2018 with dignoses including, but not limited to, Muscle weakness, Acute and Chronic [MEDICAL CONDITION], unspecified with [MEDICAL CONDITION] or hypercapnia, Athscl [MEDICAL CONDITION] of native coronary artery without [MEDICAL CONDITION] pectoris, Heart Failure, [MEDICAL CONDITION] (chronic) (peripheral), Essential Hypertension, [MEDICAL CONDITION], Type II Diabetes Mellitus, Spinal Stenosis-lumbar region without [MEDICAL CONDITION] claudication, allergic rhinitis, [MEDICAL CONDITION] Stage 3, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], Major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], unspecified hearing loss, nausea with vomiting, unspecified Dementia without behavioral disturbance, pressure ulcer right and left heel unstageable. Review of the medical record revealed that Resident #22 was transferred to the hospital on [DATE], 07/27/2018 and 08/22/2018, all were facility initiated with no documentation that written notice was provided to the resident and Resident Represenative (RR) of the transfer. During an interview on 10/09/2018 at approximately 12:30 PM, the Social Worker confirmed that the facility had not been providing written notification to the resident/ RR for hospital transfers. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review on 10/09/18 at 11:59 AM revealed that the resident had multiple recent hospitalization s: (1) From 7/26/18 to 7/30/18 for Acute Hypoxic [MEDICAL CONDITION] and Exacerbation of [MEDICAL CONDITION], (2) From 8/14/18 to 8/17/18 for Shortness of Breath, Oxygen Saturation of 64% [MEDICAL CONDITION] Facial and Bilat… | 2020-09-01 |
| 45 | 45 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 640 | B | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that required assessments were completed and/or transmitted as required for 4 of 4 residents reviewed for missing assessments. Four residents were noted with last transmission dates of greater than 120 days. Discharge assessments were not completed for three of these residents (Residents #315, #316, and #317). Resident #1 did not have a Quarterly Minimum Data Set (MDS) assessment transmitted. The findings included: Review of the MDS (Minimum Data Set) 3.0 Missing OBRA Assessment CASPER Report on 10/8/18 revealed the following: -The last assessment transmitted for Resident #317 was 4/1/18. -The last assessment transmitted for Resident #316 was 10/29/17. -The last assessment transmitted for Resident #315 was 10/15/17. -The last assessment transmitted for Resident #1 was 4/29/18. During an interview on 10/09/18 at 2:10 PM, the MDS Coordinator stated that Resident #317 was discharged on [DATE], #316 was discharged on [DATE], and #315 was discharged on [DATE]. No discharge assessments had been completed and transmitted for these residents. Additionally, s/he confirmed that the quarterly assessment for Resident #1 had an assessment reference date of 7/22/18 but had not been transmitted. | 2020-09-01 |
| 46 | 46 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 684 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow physician's orders for use of siderails and failed to follow standards of practice to address [MEDICAL CONDITION] for one of one sampled resident reviewed for range of motion (Resident #8). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 10:51 AM, 1:11 PM, 3:39 PM, and 4:51 PM; on 10/08/18 01:03 PM; on 10/10/18 at 2:01 PM) revealed that the resident's right hand was [MEDICAL CONDITION], had a handroll in place, and was not kept elevated, both in and out of bed, to assist in decreasing the swelling. During an interview on 10/09/18 at 2:56 PM, Certified Nursing Assistant #2 verified the [MEDICAL CONDITION] of the right wrist and hand and that it had not been kept elevated. Record review on 10/09/18 at 3:02 PM revealed Physician's Orders for one siderail to be up. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 3:39 PM, and 4:51 PM; on 10/10/18 at 2:01 PM) revealed the resident in bed with both half siderails elevated. During an interview on 10/09/18 at 3:49 PM, Licensed Practical Nurse #2 verified the Physician's Order and observed/confirmed that half rails were elevated on both sides of the bed. | 2020-09-01 |
| 47 | 47 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 698 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain consistent on-going communications with the [MEDICAL TREATMENT] center to ensure continuity of care for one of one sampled resident reviewed for [MEDICAL TREATMENT] (Resident #57). The findings included: The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/09/18 at 2:31 PM revealed that on 8/14/18 at 4:14 AM, the resident was sent to the emergency room (ER) with shortness of breath and an oxygen saturation of 64% on 2 liters per minute. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 8/28/18, the resident was again sent to the ER with shortness of breath and an oxygen saturation of 77%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 9/11/18, the resident was sent to the ER with shortness of breath and congestion. Oxygen saturation of 76%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 10/2/18, Resident #57 was sent to the ER with shortness of breath, a feeling of heaviness in the chest, and an oxygen saturation of 74%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . Further review revealed no laboratory reports on file from [MEDICAL TREATMENT] since 4/18. Following a call from the facility, the [MEDICAL TREATMENT] center faxed 4/18 through 9/18 lab results which were provided by the Assistant Director of Nurses. Review of [MEDICAL TREATMENT] Flow Sheets from 7/3/18 through the dates of … | 2020-09-01 |
| 48 | 48 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 756 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the pharmacist failed to identify irregularities for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documentation of physician recommendation regarding evaluation of risks versus benefits of continued use. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. Review of the Medication Regimen Review reports on 10/11/18 at 1:31 PM revealed no references to long term use of [MEDICATION NAME] antibiotic therapy and inherent risk of antibiotic resistant bacterial infections. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. | 2020-09-01 |
| 49 | 49 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 757 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow a procedure for 1 of 5 sampled residents reviewed for unnecessary medication to ensure that medication administered for excessive duration is reviewed for continued use. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documented evidence of evaluation of risks versus benefits. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. During an interview on 10/10/18 at 2:49 PM, when asked about the continued use of the antibiotic, the Assistant Director of Nurses stated that the resident had been admitted on an antibiotic for UTIs. S/he stated,We usually try cranberry and UTI Stat. I think we tried to take (the resident) off of it but the family wanted her (him) back on it. | 2020-09-01 |
| 50 | 50 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 761 | D | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to dispose of expired medications in the North Unit medication room and the North 2 (N2) medication cart, 1 of 1 Unit reviewed. The findings included: Observation of the N2 unit medication cart on 10/10/18 at 08:43 AM revealed 1 vial of [MEDICATION NAME] 0.083% 2.5 mg (milligrams) per 3 ml (milliliters) with an expiration of September, (YEAR) and 1 473 ml bottle of [MEDICATION NAME] 160 mg per 5 ml Elixer with an expiration date of 08/18 which was close to full. Licensed Practical Nurse #3 confirmed the expiration dates at 08:50 AM on 10/10/18. | 2020-09-01 |
| 51 | 51 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 600 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility staff failed to ensure 1 of 24 sampled residents (Resident #17) was free from possible neglect. On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 turned the resident onto her side but failed to ensure the resident was safe from falling. As a result, Resident #17 fell from the bed and struck her head on the corner of a chair that was sitting next to the bed. The resident sustained [REDACTED]. The findings included: Review of the facility's policy entitled Perineal Care (Peri-care) (undated) revealed the following: Purpose: 1. To cleanse the perineum; 2. To prevent infection and odors. Equipment: 1. Soap and water; 2. Bath basin; 3. Washcloths and towel. Procedure: 1. Explain procedure to the resident and bring equipment to the bedside; 2. Provide privacy for the resident; 3. Assist the resident to void first if they need to; 4. Do perineal care at least one time a day with bath and PRN (as needed); 5. Cleanse the area with warm water and soap. When washing the area, always wash from the front to back (sic). Be careful not to pull the washcloth from the anal area to the vaginal area; 6. Rinse the area; 7. Towel blot dry the area; 8. Assist the resident to a comfortable position; 9. Return equipment to its proper area; 10. Wash hands; 11. Chart care rendered. Notify the appropriate person of any abnormal findings. The policy did not address adjustment of residents' bed heights, or the use of side rails during peri-care. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. Continued review noted neglect was … | 2020-09-01 |
| 52 | 52 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 610 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, the facility failed to thoroughly investigate and prevent the possibility of further neglect from occurring for 1 of 24 sampled residents (Resident #17). On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 failed to ensure the resident was safe from falling and as a result, Resident #17 fell and sustained lacerations to the left eyebrow and left upper cheek. According to the facility's Investigation Report, only CNA #6 and the assessing Registered Nurse (RN) #2 were interviewed regarding the incident. In addition, CNA #6 was not suspended pending the outcome of the investigation. The findings included: Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. All reports of possible abuse are promptly and thoroughly investigated by facility management. Residents and staff are protected during incident investigation by ensuring reports are made without fear of retaliation and that anonymous reports are investigated. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provid… | 2020-09-01 |
| 53 | 53 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 657 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility nursing staff failed to update 3 of 24 sampled residents' care plans (Residents #15, #16, and #17). The findings included: Review of the facility's Policy and Procedure for RAI (Resident Assessment Instrument)/Care Plans (not dated) revealed 3. Care plan team meets every Thursday to review care plan with family and residents who choose to attend unless arrangements are made for different time or date. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #15 exhibited no behaviors (i.e. no physical behaviors and no self-injurious behaviors) and no signs/symptoms of depression, during the assessment periods. According to the MDS, Resident #15 required the extensive assistance of one staff person for bed mobility, transfers, toileting, dressing, walking in the room, and locomotion on and off the unit. The Annual MDS assessment, noted Resident #15 had impairment to one side of lower extremities and utilized a wheelchair for mobility. Resident #15 had no falls during either MDS assessment period. Continued review of the MDS revealed Resident #15 was administered no anti-coagulant medications; however, the resident did receive antipsychotic medication for seven (7) days during the assessment period. Review of Resident #15's Progress Notes revealed the following: 11/11/8 - While the CNA had the resident in the bathroom, she noticed bruises on resident's left arm, reddish purple in color. The resident was not able to state what might have happened. No complaint of pain or sign or symptom of pain noted to left arm when touched. Resident was able to move bilateral upper extremities on her own without difficulties or distress noted. No swelling noted to left arm. Resident observed by nur… | 2020-09-01 |
| 4246 | 4246 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2016-08-18 | 332 | D | 0 | 1 | QPUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure that the medication error rate was less than 5 % (percent). There were 2 errors out of 27 resulting in a medication error rate of 7.7%. The findings include: ERROR # 1: On 8/15/16 at approximately 4:19 PM during medication pass observation LPN (Licensed Practical Nurse) # 1 administered one tablet of [MEDICATION NAME] 1,000 mg (milligram) to Resident # 67. During medication pass reconciliation a review of the physician's orders [REDACTED]. On 8/15/16 at approximately 4:32 PM LPN # 1 reviewed the physicians order and MAR (medication administration record) and verified that the medication had not been administered with the evening meal which was due to be served at approximately 5:30 PM. ERROR # 2: On 8/16/16 at approximately 8:15 AM during medication pass observation RN (Registered Nurse) # 1 administered 9 medications to Resident # 24 and at approximately 8:20 AM stated that all medications had been given. During medication pass reconciliation on 8/16/16 at approximately 8:24 AM a review of the physician's orders [REDACTED].* [MEDICATION NAME] 5MG ROX TAKE ONE TABLET BY MOUTH EVERY other DAY 9AM. This medication had not been recorded by the Surveyor as having been administered by RN # 1. On 8/16/16 at approximately 8:30 AM RN # 1 reviewed the physicians order and MAR and stated that the [MEDICATION NAME] had not been administered as ordered. | 2020-04-01 |
| 5377 | 5377 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2015-04-24 | 152 | D | 0 | 1 | BTZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy titled Advance Directives Policy, the facility failed to afford residents the right to formulate their own advanced directives or verify that the resident's responsible party and/or family member had the authority to make healthcare decisions for 2 of 17 residents reviewed. Resident #112 and #142 were both deemed competent and the responsible party and/or family member signed the residents' Code Status Form. The findings included: The facility admitted Resident #112 with [DIAGNOSES REDACTED]. Review of the Medical Record on 4/24/15 revealed a Cheraw Healthcare Code Status Clarification and Competency Form dated 12/30/14 and 1/5/15 in which two physician's deemed that Resident #112 was able to make health care decisions. Further review revealed a family member signed the Code Status form for the resident to be a Do Not Resuscitate(DNR) on 12/26/14. Review of the Social Services Progress Note dated 12/26/14 stated the resident asked for her daughter to sign all paperwork. Further review revealed the daughter who is the Responsible Party for the resident did not sign the paper work but the granddaughter signed. During an interview with the Social Services Coordinator(SSC) on 4/24/15 at 5:08 PM, he/she stated that he/she did not admit the resident and that she had knowledge of the resident not feeling well at the time of admission. He/she continued by stating on admission the facility asks if the resident has a Power of Attorney or Living Will. The facility goes over what advance directives entails and it is also in the facility's admission packet. During the admission process, we discuss life support. If the resident is in attendance at the time of the meeting, he/she signs the paperwork if not, the family signs. The SSC stated upon returning to work he/she had spoken to the resident and it was the resident's wishes to be a DNR and he/she had just neglected to document or have … | 2018-12-01 |
| 5378 | 5378 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2015-04-24 | 431 | E | 0 | 1 | BTZB11 | Based on observations, interviews and review of the facility's agreement with pharmacy titled,Consultant Pharmacist Retainer Agreement, and the facility policy titled, Medication Storage in the Facility, the facility failed to ensure 2 medications, packaged by the pharmacy, contained lot numbers and expiration dates. The facility further failed to ensure expired medications were removed/destroyed and not stored with other medications available for resident use in 3 of 4 medication carts and 1 of 2 treatment carts. The findings included: An observation on 4/22/2015 at approximately 2:25 PM of the South Hall 2 medication cart revealed Norco 10/325 milligrams (mg) with RX # 43 with a total of 75 tablets had neither an expiration date nor a lot number. During an interview on 4/22/2015 at approximately 2:25 PM with Licensed Practical Nurse (LPN) #1 and #2 confirmed the medication, Norco, had neither an expiration date nor a lot number. An observation of the South Hall medication storage room on 4/22/2015 at approximately 2:40 PM revealed the medication Lovaza RX # 95 had neither an expiration date nor a lot number. An interview on 4/22/2015 at approximately 2:45 PM with Registered Nurse #1 confirmed the Lovaza packaged by the pharmacy had neither an expiration date nor a lot number. An observation on 4/22/2015 at approximately 3:00 PM of the South Hall treatment cart revealed Neosporin Ointment Lot #0122LZ with and expiration date of 12/2013. An interview with Registered Nurse (RN) #1, he/she confirmed the Neosporin Ointment had expired on 12/2013. An observation on 4/24/2015 at approximately 10:00 AM of the North Hall 1 medication cart revealed Altachlore 5% ointment - Sodium Chloride Hypertonicity Opthalmic Ointment expired on 1/2015. The instructions read, Apply to ocular surface 2 times daily. The medication included a RX # 44 and NDC # -184-50 and was Manufactured by Altaire. The Altachlore 5% Ointment was sent into the facility by pharmacy on 3/21/2015. An interview on 4/24/2015 at approximately 10:12 AM with LP… | 2018-12-01 |
| 6761 | 6761 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2013-09-12 | 152 | D | 0 | 1 | FS9511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, interviews, review of the South Carolina Code of Laws (Unannotated) Title 44 Chapter 66 Adult Health Care Consent Act, and review of the facility's policy entitled Patients Without Advance Directives, the facility failed to ensure that 2 licensed physicians signed the Code Status Clarification and Competency Form declaring Resident #7 lacked capacity to make health care decisions, 1 of 24 residents reviewed for code status. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 9/10/13 at approximately 3:40 PM, record review revealed a Code Status Clarification and Competency Form dated 5/24/13 and signed by the Advanced Nurse Practitioner (ANP) on 6/3/13 and by the physician on 6/5/13. During an interview on 9/11/13 at 4:45 PM, the Social Services Director (SSD) confirmed the ANP had signed the statement of non-competency and was unaware that the ANP did not have authority to sign the form. Review of the South Carolina Code of Laws (Unannotated) Title 44 Chapter 66 Adult Health Care Consent Act Section 44-66-20 (6) revealed .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Review of the facility's policy entitled Patients Without Advance Directives on 9/12/13 at approximately 12:00 PM revealed 3. The patient's inability to consent to care or to make health care decisions must be certified by two licensed physicians, each of who has examined the patient. The policy further outlined the documentation required of the certification of a resident's inability to consent. | 2017-09-01 |
| 7965 | 7965 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2012-07-18 | 253 | E | 0 | 1 | RSSS11 | On the days of the survey, based on observations, interviews and review of the facility's policy for Infection Control (Housekeeping/Laundry), the facility failed to maintain sanitary conditions for 7 out of 10 shower rooms examined as evidenced by black and pink substances noted on multiple shower chairs, hair and dark spots on multiple shower floors and unpleasant odors detected in 2 of 7 shower rooms. The findings included: Observations on 7/17/12 at approximately 11:30 am of the shower room on the right side of the hall containing rooms 100-107 revealed a shower stall with a yellowish substance and dark spots on the shower floor. Observations on 7/17/12 at approximately 11:32 am of the shower room on the left side of the hall containing rooms 100-107 revealed a shower stall with dark spots on the floor of the shower. Observations on 7/17/12 at approximately 11:35 am of the shower room on the hall containing rooms 108-122 revealed a navy blue shower chair with a black substance in a large number of the piping joints, under the mesh seat on the piping, and above the wheels. There was also noted a strong unpleasant odor within the room and dark spots on the privacy curtain. Observations on 7/17/12 at approximately 11:40 am of the shower room on the hall containing rooms 123-134 revealed the shower stall with dark spots and hair on the floor of the shower. Within the shower stall was a navy blue shower chair with a whitish/pink substance on the back of the shower chair. Also, the navy blue shower chair had a black substance in multiple joints of the piping. There was also noted an unpleasant odor within the room and the privacy curtain had dark spots on the fabric. Observations on 7/17/12 at approximately 11:50 am of the shower room on the left side of the hall containing rooms 200-207 revealed the shower stall floor had dark spots and within the shower stall was a green shower chair with a black substance along the mesh seam of the back of the chair. Observations on 7/17/12 at approximately 11:55 am of the showe… | 2016-09-01 |
| 7966 | 7966 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2012-07-18 | 371 | E | 0 | 1 | RSSS11 | On the days of the survey, based on observation and interview, the facility failed to store food under sanitary conditions. There was prepared food stored under raw bacon and juice boxes past the use by date. The findings included: During tour of the kitchen on 7/17/12 at approximately 8:15 a.m. and 11:35 a.m., three trays of uncooked bacon and two boxes of uncooked bacon were noted on an upper shelf in the walk in refrigerator. There were two trays of pureed desserts and two pans of prepared cake on the shelf underneath the uncooked bacon. One tray of pureed desserts was not covered. On 7/17/12 at approximately 11:20 a.m., two boxes of fruit punch juice with a use by date of 3/29/12 was stored in the dry storage room. The two boxes were located at the back of the shelf behind boxes of fruit punch juice that were not past the use by date. The Certified Dietary Manager (CDM) confirmed the findings during interview on 7/17/12 at approximately 11:40 a.m. | 2016-09-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );