cms_SC
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10,300 rows sorted by facility_name
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| Link | rowid | facility_name ▼ | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 488 | 488 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 550 | E | 1 | 1 | 8N1U11 | > Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Three to four residents were served or being assisted with eating by staff at one table while 18 plus residents were seated at tables in the dining room on the 100 Unit with clothing protectors in place for over 45 minutes and not served or eating.1 of 2 Unit dining rooms observed. The findings included: During a random lunch observation on 1/14/19 at approximately 11:50 AM of the dining room on the 100 Unit revealed residents seated in the dining room on the 100 Unit and residents being transported to the 100 Unit dining room. Staff was observed offering and placing clothing protectors on all residents in the dining room. At approximately 12:15 PM, one table with four (4) residents were served with two of the four residents requiring staff assistance with eating. There were two long tables with multiple residents and two smaller tables with three to four residents with clothing protectors on waiting to be served. Some residents were looking at the table were the residents were eating independently or being assisted by staff. At approximately 12:26 PM two food carts were delivered pass the residents seated in the dining room down the hallways while the resident remained in the dining room on the 100 Unit not served or eating. One resident was observed self-ambulating from the dining table in his/her wheelchair. The resident asked staff when the food was coming. Staff informed the resident not to leave the table because lunch was coming. During an interview on 1/14/19 at approximately 12:46 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 revealed the residents at the table being served is restorative dining residents. Both confirmed the observations of 4 residents seated at a dining table and eating or being feed while other residents were waiting to be served. RN #2 and LPN#1 stated the facility has been delivering food to the dining room t… | 2020-09-01 |
| 489 | 489 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 580 | D | 1 | 1 | 8N1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents responsible parties were notified of changes that affected the resident's care while in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134's responsible party was not notified of a skin tear that required a bandage/dressing. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LF[NAME] Further review of Resident #134's record revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred, and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and did not document the incident. RN #1 stated the facility did not notify the family prior to the first bandage/d… | 2020-09-01 |
| 490 | 490 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 842 | D | 1 | 1 | 8N1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that a resident's medical record accurately document the care and services that was received while placed in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134 with treatment being given without documentation as to what occurred that required treatment. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA prior to 5/07/18. During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and wrote no documentation. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did no… | 2020-09-01 |
| 491 | 491 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 241 | E | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, facility failed to maintain the dignity of residents during meal service on 2 of 2 units. Resident room trays were not distributed in a sequential manner on Unit 1. The privacy curtain was not pulled for a resident who was fed by Gastrostomy tube, when other residents were served in the room. Residents were not offered glasses for canned drinks and supplements served in cartons on Units 1 and 2. Resident #85 was served with plastic utensils without documented current need. The findings included: During observation of the noon meal on 03-13-17 at 12:38 PM, Certified Nursing Assistant (CNA) #1 was the only staff member distributing room trays on Unit 1. S/he served the resident nearest the door in room [ROOM NUMBER], but did not provide a tray for the second occupant in the room or pull the privacy curtain before moving on to the next room (room [ROOM NUMBER]). It was approximately 20 minutes before the second resident in room [ROOM NUMBER] was served. room [ROOM NUMBER] was occupied by 3 residents. CNA #1 served 2 of the 3 residents sequentially. The third resident was nourished by use of a gastrostomy (G-) tube. The CNA did not pull the privacy curtain between residents. Therefore, the resident with the [DEVICE] was fully able to see other residents eating their meals. During meal observation on 03-14-17 at 12:35PM, all residents in the dining rooms on Units 1 and 2 who were served Ready Shakes and/or canned sodas were not offered or provided with glasses for these beverages. During an interview on 03-14-17 at 12:50PM, Registered Nurse (RN) #2 indicated that some residents preferred to have their beverages directly from the container. S/he stated that the kitchen usually sent extra cups on the set up cart. No extra cups/glasses were noted during observed meal times. On 03-14-17, Resident #85 was observed eating with plastic utensils in the Wing 2 dining room at 8:40 AM and at 12:40 PM. Review of the reside… | 2020-09-01 |
| 492 | 492 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 329 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of non-pharmacological intervention prior to administration of an antipsychotic for 1 of 5 sampled residents reviewed for unnecessary medications. Staff administered [MEDICATION NAME] multiple times to Resident #36 without documented evidence of behaviors and/or evidence of non-pharmacological interventions prior to administration. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 3-15-17 at 12:08PM revealed physician's orders [REDACTED]. Review of behavior monitoring for (MONTH) through March, (YEAR) on 3/16/17 revealed no documented behaviors. Review of the Medication Administration Records revealed that [MEDICATION NAME] was administered twice in 1-17 (on 1-1-17 and 1-20-17), six times in 2-17 (on 2-8-17, 2-9-17, 2-19-17, 2-23-17 x 2, and 2-24-17), and five times in 3-17 (on 3-3-17, 3-4-17, 3-5-17, 3-9-17, and 3-10-17) for yelling out, hollering out, agitation, and anxiety. Review of Nurse's Notes revealed there was no evidence of evaluation of the underlying cause of the behavior and no attempts at non-pharmacological interventions prior to administering the medication. There were no behaviors documented when agitation or anxiety was noted as the reason for administration of the medication. Review of the care plan revealed When res(ident) noted to be yelling out, paranoid, agitated after misinterpretation of others actions or conversation, staff to approach calmly, attempt to get res to talk, give time to express self, take res to a more comfortable area, offer snacks and liquids, and if this does not work offer to take back to room. Reassure res r/t (related to) whatever is causing her (him) agitation. Make nurse aware of behaviors and meds as ordered. Call her (his) daughter or other family member when requested. During an interview on 3-16-17 at 9:44AM, Licensed Practical Nurse (LPN) #1 stated that pr… | 2020-09-01 |
| 493 | 493 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 428 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure that irregularities identified by licensed pharmacist during drug regimen review were addressed in a timely manner by the attending physician for one of five residents reviewed for unnecessary medications. The findings included: Resident #23 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/17 at 4:30 PM revealed that the Consulting Pharmacist initiated three Note to Attending Physician/ Prescriber communication forms on 11/22/2016 regarding recommendations related to irregularities identified during monthly medication regimen review for resident #23. Review of one of the three recommendations submitted by the Licensed Pharmacist on 11/22/2016 revealed request submitted for consideration of Gradual Dose Reduction (GDR) for hypnotic medication from scheduled to as needed (PRN) dosing, this request was not addressed by the Family Nurse Practitioner (FNP) until 2/2/2017, when it was approved. Review of a second communication form submitted by the Licensed Pharmacist on 11/22/2016 addressed irregularity regarding fasting blood glucose levels and request for consideration to change dose of Lantus insulin from 10 units every 12 hours to 20 units every morning to address this issue, which was not addressed by the FNP until 2/2/17, where the request was denied with the following reason provided resident has had multiple hyperglycemic episodes- Lantus increased-HgbA1c 7.8 on 11/21/16. Review of the third communication form submitted by the Licensed Pharmacist on 11/22/2016 revealed that resident #23 was identified with weight loss, difficulty swallowing, and abnormal Thyroid Stimulating Hormone (TSH) laboratory test results with request for consideration to change medication dose for Levothyroxine followed by labs in 8 weeks, where the request was not addressed until 2/2/17 when it was approved and medication was cha… | 2020-09-01 |
| 494 | 494 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 431 | D | 0 | 1 | 3CJJ11 | Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 3 of 8 medication carts and 2 of 2 units reviewed. Expired medications were on the medication carts after the expiration date. The findings included: On 3/13/17 at 12:24 PM, an observation with RN#1 of the Hall 1/Unit 1 medication cart revealed a Novolog FlexPen (Lot #FP ) with approximately 225 units of fluid insulin remaining. The Novolog FlexPen had an open date of 2/10 and expiration date 3/10. Following the observation, RN #1 verified the Novolog FlexPen was expired and stated, The insulin pen should have been removed from the cart. On 3/14/17 at 1:20 PM, an observation with RN #2 of the Hall 2/Unit 1 treatment cart revealed 1-2-3-Paste with a pharmacy stamped expiration date of 1/24/17. Following the observation, RN #2 verified the 1-2-3 Paste was expired and indicated the paste should have been removed from the cart. On 3/14/17 at 1:45 PM, an observation with RN #1 of the Hall 1/Unit 2 treatment cart revealed Premarin vaginal cream .625 mg/g with a manufactures stamped expiration date of 9/16. Following the observation, RN #1 verified the Premarin vaginal cream was expired and indicated the cream should have been removed from the cart. On 3/14/17 at 10:45 AM, a review of the facility policy entitled, Medication Storage in the Facility, revealed under Expiration Dating (Beyond-use dating), procedure ([NAME]) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 3/14 at 2:55 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Nov… | 2020-09-01 |
| 495 | 495 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 441 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review, the facility's laundry contractor failed to follow agreed upon policy and procedure for transfer of soiled linen from the facility on 1 of 2 units reviewed for Infection Control. The findings included; Observation of the facility's contracted Laundry Service delivering and retrieving laundry on 03/16/17 at 10:14 am revealed that the handler used an unlined and unmarked container which was used to bring clean linen to the facility to retrieve soiled linen. The handler also placed unbagged soiled linen in the container. In an interview on 03/16/17 at 10:14 am while loading the container into the vehicle for transport, the handler stated that the carts are cleaned once or twice a week. Subsequent review of the contractor's policy revealed that Soiled linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers using a large bin For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linens. During observations from 3-13-16 through 3-16-17, resident care equipment was stored in an improper/unsanitary manner: (1) An uncovered, unlabeled bedpan was initially noted on the floor behind the toilet in room [ROOM NUMBER] (semi-private) bathroom on 03/13/2017 at 3:04 PM. (2) On 03/14/2017 at 9:35 AM, an uncovered, unlabeled bedpan was found on the grab bar in the bathroom for room [ROOM NUMBER] (semi-private). An environmental tour was conducted with the Housekeeping/Environmental Manager, Plant Maintenance Manager, Area Manager and Assistant Maintenance Manager on 3/16/17 at 2:35 PM. The bedpans had not been moved or properly stored for the duration of the survey. All staff present verified the storage of the items. The Housekeeping Manager stated that this concern was the responsibility of the nursing department. During an interview on 3/16/27 at 2:54 PM, Registered Nurse (RN) #3 verified that t… | 2020-09-01 |
| 496 | 496 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 582 | C | 0 | 1 | PQLY11 | Based on record review and interviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/Centers for Medicare/Medicaid (CMS) form to 3 of 3 sampled residents reviewed for Medicare Part A Services. Residents #38, #44 and #80 received the Notice of Medicare Non-Coverage (NOMNC), but did not receive the required SNFABN/CMS form. The findings included: Review of the medicare non coverage notices on 12/04/17 at approximately 3 PM revealed Residents #38, #44 and #80 had services ended with additional days left for services. There was no CMS forms provided by the facility. During an interview on 12/04/17 at approximately 3:10 PM with the Administrator, the Administrator confirmed the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (CMS ) form for Residents #38, #44 and #80. The Administrator stated the CMS would only be given if it was requested by the resident/responsible party. An interview with the facility consultant on 12/05/17 at approximately 3:48 PM revealed the facility does not provide the SNFABN/CMS form until the resident/responsible party request they want to appeal the Medicare non coverage decision. | 2020-09-01 |
| 497 | 497 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 641 | D | 0 | 1 | PQLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of assessments. Resident #23's Minimum Data Set (MDS) was coded inaccurately for insulin administration, diuretics, and Urinary Tract Infection (1 of 1 sampled resident reviewed for hospitalization ). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During record review of the MDS on 12/5/17 at 2 pm revealed the MDS with assessment review date (ARD) of 9/25/17 had Insulin coded as 0 under medications, and did not have the [DIAGNOSES REDACTED]. Further review of the MDS ARD of 10/24/17 revealed Urinary Tract Infection was not coded under active diagnoses, and had diuretics inaccurately coded as 7 under medications. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for a UTI. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse #1 verified inaccurate coding on the 9/25/17 MDS regarding Insulin, and did not code the presence of a UTI. S/he also verified the inaccurate coding on the 10/24/17 MDS regarding diuretics under medications. | 2020-09-01 |
| 498 | 498 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 657 | D | 0 | 1 | PQLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan. Resident #23 was hospitalized and treated for [REDACTED].# 13 did not include a problem and interventions regarding Blepharitis of the left eye (1 of 1 sampled resident for infections, and 1 of 2 sampled residents reviewed for UTI). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for treatment of [REDACTED]. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse (RN) #1 verified the comprehensive care plan was not updated to reflect the UTI or antibiotic therapy on 9/7/17 or 10/26/17 after readmission to the facility from the hospital. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 1:45 pm, Resident #13 was noted to have a large amount of dried beige drainage to the left eye and eyelash with swelling and redness of the lower lid. Review of the care plan on 12/5/17 at 4 pm revealed no evidence in the care plan to address the chronic Blepharitis condition of left eye drainage, redness and swelling or the ordered interventions including antibiotic eye ointment and cleansing of the eye with baby soap twice a day. During an interview on 12/6/17 at 10:25 am, MDS RN #1 verified there was no comprehensive care plan to address the Blepharitis [DIAGNOSES REDACTED]. | 2020-09-01 |
| 5237 | 5237 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 157 | D | 0 | 1 | PY4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician/nurse practitioner and/or other qualified professional of significant weight loss for Resident #12, 1 of 3 residents reviewed for nutrition. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. During the Stage I Census Record review at 5:14 PM on 6/13/16, Resident #12 was noted to have a significant weight loss. On 6/16/16 at approximately 3:15 PM, record review revealed the resident's weight on 6/15/16 was 96.0, on 6/1/16 96.7 pounds, on 5/04/16 106.1 pounds, on 3/08/16 109.0 pounds and on 11/4/15 110.2 pounds. Review of the Nurse's Notes revealed no documentation that the physician, family or Registered/ Licensed Dietitian was notified of the resident's significant weight loss. There was no documentation of any recent changes in dietary intake or [MEDICAL CONDITION], diarrhea or vomiting. Record review revealed the RD completed an assessment dated [DATE] and noted the resident consumed 50-75% of meals and recommended ReadyCare. The RD had not re-assessed the resident related to the significant weight loss. During an interview at 2:59 PM on 06/16/2016, the Certified Dietary Manager (CDM) reviewed the weight sheets and stated that Resident #12 was not on the list for weight loss and that a weight for (MONTH) had not been recorded. When informed that the resident's weight on (MONTH) 1st was 96.7 pounds, the CDM stated and that's a major loss. The CDM stated for a resident under 100 pounds, a re-weight is done if there is a difference of 3 pounds and the unit manager notified. The CDM stated that s/he would then be notified and in turn notify the RD. In addition, the CDM stated the RD had been at the facility on 6/15/16 and had not been informed. During an interview at 3:27 PM on 06/16/2016, the Director of Nursing (DON) provided documentation of the (MONTH) weights but stated that the Dietary manager informed her that she had not … | 2019-02-01 |
| 5238 | 5238 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 274 | D | 0 | 1 | PY4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment upon identification of decline in continence, development of a pressure ulcer, and decline in bed mobility for Resident #20, 1 of 2 residents reviewed with a Significant Change in Status. The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. At 3:31 PM on 06/15/2016, comparison of the 2/3/16 Admission MDS (Minimum Data Set) to the 4/18/16 Quarterly MDS revealed the resident had an improvement in her/his BIMS (Brief Interview for Mental Status) score, mood and behaviors. The resident was also noted to have a decline from limited assistance to extensive assistance with bed mobility, a decline in continence from occasional to frequent incontinence, and the development of a Stage III pressure ulcer. Review of the Care Plan Progress Notes revealed a note dated 4/21/16 that stated the resident was noted to have decline in the following areas; incontinence, pressure ulcer stage 3 to sacrum, pain symptoms, and one area of ADLs (Activities of Daily Living) (bed mobility). Will begin Significant change review. There was no documentation or results of a review for a significant change in the record. On 6/16/16 review of the Bladder Incontinence Evaluation done 4/11/16 revealed the resident had incontinent episodes daily and was updated on 4/20/16 that indicated the resident remained frequently incontinent of bladder. During an interview at 5:31 PM on 06/15/2016, the RN MDS Coordinator stated the IDT (Interdisciplinary Team) had determined the resident did not have a significant change in status. During the interview, the Social Services Director reviewed the chart and confirmed there was no documentation of an IDT review or determination that the resident had returned to baseline. The MDS Coordinator stated the pressure ulcer was healed on 4/26/16. At 12:09 PM on 06/16/2016 the MDS Coordinator confirmed the docume… | 2019-02-01 |
| 5239 | 5239 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 281 | D | 0 | 1 | PY4411 | Based on observation, interview and review of the facility's policies, 1 of 5 nurses observed during the Medication Pass failed to meet professional standards of practice during medication administration for Resident #56. LPN #1 dropped a pill during med pass, retrieved it from the floor and administered it to the resident. The findings included: During medication pass observation on 06/16/2016 at 9:40 AM , LPN (Licensed Practical Nurse) #1 dropped a pill from the medicine cup onto the floor. The LPN picked up the pill, placed it back in the medicine cup and administered it. During an interview on 06/16/2016 at 9:43 AM, the LPN confirmed s/he dropped the pill on the floor, picked it up and proceeded to administer the medication. The LPN then asked what would be the right thing to do in that case. Review of the facility policy entitled Medication Storage in the Facility revealed Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction . Review of the policy entitled Oral Medication Administration Procedure 6. a. page 20 revealed Avoid touching medications if at are possible. | 2019-02-01 |
| 6492 | 6492 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2015-05-14 | 281 | D | 0 | 1 | RC2511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of the policy provided by the facility entitled Administration of Insulin, a facility nurse failed to properly administer Insulin to Resident #77, 1 of 1 resident observed during medpass for the administration of Insulin. The nurse failed to keep the [MEDICATION NAME] needle embedded in the skin for the appropriate time frame to ensure the full amount of Insulin had been administered. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Observation on 5/13/15 at approximately 4:10 PM revealed Licensed Practical Nurse (LPN) #1 administering 4 units of [MEDICATION NAME] Insulin via flex pen to Resident #77 for a fingerstick blood sugar of 250. The nurse injected the Insulin into the resident's left upper arm and held the flex pen in place for less than 2 seconds before removing it. After removing the flex pen, the nurse immediately pulled the resident's sleeve down and the surveyor was unable to determine if there was any leakage of Insulin. During an interview after the medpass observations of the nurse, the surveyor asked LPN #1 if s/he was aware that there was a specified amount of time that the flex pen needle was to stay under the skin while administering the Insulin. The surveyor informed the nurse that s/he had been observed to leave the needle in for less than 2 seconds. LPN #1 thought s/he had kept the needle under the skin for 2-5 seconds; and was unsure of the required time frame. On 5/13/15 at 4:17 PM, the Unit Manager was asked about how long the flex pen needle would need to stay under the skin. The Unit Manager was unsure, and stated s/he would check the policy to make sure of the timeframe. Registered Nurse (RN) #1 spoke with the consultant pharmacist by phone and reported that the consultant pharmacist had stated that to ensure the full dose of Insulin had been given with the [MEDICATION NAME], that s/he recommended the nurse hold the pen needle in p… | 2018-01-01 |
| 7228 | 7228 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2014-02-07 | 371 | E | 0 | 1 | MMNO11 | On one day of the survey, based on observations, interviews, and review of the facility policy titled Employee Guidelines-Infection Control Practices and Food Handling Guidelines, the facility failed to serve and distribute food under sanitary conditions. Observations during the lunch meal distribution on the 100 Unit and 200 Unit Halls and 100 Unit Day area revealed facility staff touched food items with their bare hands. The findings included: Observation on 2/4/14 at approximately 12:45 PM revealed staff serving trays and setting-up residents' lunch in the 100 Unit day area. The menu included cornbread delivered in a paper wrapping. Observation revealed RN #1 and CNA's #1, 2, and 3 reached into the package, retrieved the cornbread with their bare hands, and placed the cornbread onto the plate when serving residents. In addition, RN #1 was observed to take the cornbread into his/her bare hands, break the bread into two pieces, and place the pieces into containers beside the plate while serving one of these residents. During an interview with CNA #3 on 02-07-14 at approximately 11:30 AM, he/she confirmed the surveyor's findings. During an interview with CNA #1 on 02-07-14 at approximately 11:45 AM, he/she stated, okay. During an interview with RN #1 on 02-07-14 at approximately 2:45 PM, he/she stated, I don't remember doing this, but it should not be done. CNA #2 was unavailable for interview. Review of the facility policy titled Employee Guidelines-Infection Control Practices revealed in section All Food and Nutrition Services Employees the following: Handle plates by the bottom or the edge; keep hands off the eating surface. Keep thumb and fingers away from food on the plate. Review of the facility policy titled Food Handling Guidelines revealed in section Prevention of Food Infection the following: Minimize hand contact with food by the use of utensils or disposable gloves. | 2017-04-01 |
| 8094 | 8094 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2012-11-15 | 318 | D | 0 | 1 | ZETP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to accurately assess one of three residents reviewed for range of motion (ROM) and implement measures to prevent further decline. The facility failed to implement contracture prevention measures and failed to identify contractures of the left hand for Resident #48. There was no evidence of provision of restorative services as per the care plan to maintain ROM and to prevent contracture development. The findings included: Multiple observations on all days of the survey revealed Resident #48 holding the left hand in a fisted position. No handroll or positioning device was observed in place at any time. Significant [MEDICAL CONDITION] of the left hand was noted on 11-13-12 and 11-15-12. During the Staff Interview during Stage 1 of the survey process, the 100 Hall Unit Manager stated that Resident #48 had no contractures. Resident #48 was not noted on the contracture list provided to the surveyors on 11-13-12 after discussion related to the definition of contracture as identified during the staff interviews Review of the 10-22-12 Quarterly and 5-13-12 Annual Minimum Data Set (MDS) Assessments on 11-14-12 at 11:19 AM revealed that Resident was vision-impaired, rarely/never understood, displayed both verbal and physical behaviors toward staff, and was totally dependent for all activities of daily living (ADL's). ROM was noted as impaired in both lower extremities. Skilled therapy nor restorative nursing services were not noted as having been provided. During an interview and observation on 11-14-12 at 12:50 PM, the MDS Coordinator assessed the resident in the presence of the surveyor and verified the [MEDICAL CONDITION] of the upper extremities. The resident's left hand was fisted and no positioning was noted for the [MEDICAL CONDITION] of upper extremities or for the fisted hand. The MDS Coordinator noted that the resident had had the [MEDICAL CONDIT… | 2016-07-01 |
| 9233 | 9233 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2011-09-07 | 309 | D | 0 | 1 | RKDK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on interviews and record review, the facility failed to ensure that pacemaker checks were performed timely for Resident #9, 1 of 4 residents reviewed with pacemakers. The findings included: The facility admitted Resident #9 on 4/28/10 with [DIAGNOSES REDACTED]. Record Review of the hospital Discharge Summary on 9/6/11 at 2:40 PM revealed the resident had Pacemaker placement due to Sick Sinus Syndrome. After reviewing the record , the Director of Nursing (DON) was asked on 9/7/11 at approximately 10:15 AM where Pacemaker checks were documented. The DON stated that the Pacemaker checks were documented on the Treatment Administration Record (TAR.) She further stated that the due date for the Pacemaker check was documented on the monthly physician's orders [REDACTED]. At approximately 10:35 AM on 9/7/11, Licensed Practical Nurse (LPN) #1 confirmed she was unable to locate any documentation of a pacemaker check on the record. During an interview at 1:55 PM on 9/7/11, LPN #1 stated Resident #9 should have had an appointment at the Cardiologist's in January. She stated the resident missed that appointment and had not had a pacemaker check done since October of 2010. | 2015-06-01 |
| 7946 | 7946 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 281 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the first revisit survey based on record reviews and interviews, the facility failed to assess and/or document acute conditions for 3 of 3 residents with acute changes. Res. #18, #4, and #17 experienced acute changes in condition without assessments or documentation. Resident #18 was admitted with an order for [REDACTED].#4 and #17 had a change in condition requiring medical treatment but there was no documentation of assessment related to the treatments as administered. In addition, Resident #17 had physician orders related to monitoring intake and output which were not clarified by staff to allow for standard facility policy. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the Hospital Transfer Record dated 1/2/14 stated the resident had a history of [REDACTED]. The resident had low hemoglobin and received packed red blood cells while in the hospital. Review of the hospital Medication Administration Record [REDACTED]. The hospital discharge medications included an order for [REDACTED].n. (as needed) for [MEDICAL CONDITION]. Review of the resident's Interim Care Plan dated 1/2/2014 revealed a problem, at risk for bleeding R/T (related to) use of anticoagulant. [MEDICATION NAME] ([MEDICATION NAME]) had been checked and marked out. [MEDICATION NAME] was checked. Interventions included to monitor for bruising and bleeding and notify the MD (Medical Doctor). Review of Resident #18's Physician's telephone orders dated 1/6/2014 stated, Check CBC (Complete Blood Count) UA (urinalysis) CMP (Comprehensive Metabolic Panel) . Under the section titled Indication Dx (diagnosis) gave the reason for the lab tests as Tarry stool, dk (dark) urine. Review of the Departmental Notes revealed Nursing Notes dated 1/2/14 and 1/6/14 with no documentation related to Tarry stool, dk (dark) urine. There was no documentation of an assessment of the resident's condition or a nurse's note that stated the resid… | 2016-10-01 |
| 7947 | 7947 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 282 | D | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to ensure that an air mattress was placed as ordered as part of a pressure ulcer management program for 1 of 4 residents reviewed for pressure ulcers. (Resident #3) The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review on 10/11/13 of the resident's care plan revealed an update on 6/24/13 for an air mattress to be applied. Review of the Can ' s (Certified Nursing Assistant) instruction sheet located on the inside of the resident's closet door revealed instructions for an application of an air mattress. Observation of Resident #3 on 10/12/13 revealed the resident did not have an air mattress in place as ordered and care planned. At this time, CNA #2 confirmed the instructions on the closet door and that the resident was not lying on an air mattress. On 10/12/13 at 3:15 PM, RN (Registered Nurse) #2 confirmed the resident was not lying on an air mattress and no explanation was given. | 2016-10-01 |
| 7948 | 7948 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 309 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews, the facility failed to provide necessary care and services as ordered for one of one sampled resident reviewed for provision of treatments/care for [MEDICAL CONDITION]. The facility failed to provide wound treatments and wraps as ordered for Resident #7 who suffered from [MEDICAL CONDITION] extremities and had open wounds on both legs. The facility also failed to assess vital signs as ordered for one of three residents reviewed for falls. Staff failed to monitor orthostatic vital signs for Resident #2 as ordered. The findings included: The facility admitted Resident #7 following a fall resulting in hospitalization for treatment of [REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the 9-4-13 Admission (Nursing) Assessment on 10-11-13 revealed that Resident #7 was admitted with [MEDICAL CONDITION], though no location or severity was noted. A body audit that same date revealed 3-4+ [MEDICAL CONDITION] in bilat(eral) arms and [MEDICAL CONDITION] from genitals to feet. Record review on 10-10-13 at 9:30 AM revealed a 9-6-13 physician's orders [REDACTED]. Apply Nutrashield/Lotion to both feet q shift. Review of the 9-13 and 10-13 Treatment Records revealed that this treatment was not initialed as completed as ordered twice on 10-2-13, twice on 10-3-13 and once on 10-4-13. Also on 9-6-13, a physician's orders [REDACTED]. Review of the 9-13 Treatment Records revealed that this treatment was not initiated until 9-10-13 following a physician's orders [REDACTED]. Further review revealed that the treatment was omitted on 9-30-13 and 10-3-13, 10-4-13, and 10-5-13. Daily Skilled Nurse's Notes on 9-8-13 described Bilateral lower extremities continue to weep, and peeling skin noted from both. Both LE (lower extremities) bright red and hot to touch! Three fluid-filled blisters noted, one to L(eft)LE and two to R(ight)LE. Copious am(oun)ts of foul-smelling. pink tinged dr(ai)n(… | 2016-10-01 |
| 7949 | 7949 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 314 | D | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observation, and interviews, the facility failed to provide necessary treatment and services to promote healing and prevent new sores from developing for 2 of 4 residents with pressure sores or a history of pressure sores. Resident #3 had no air mattress as ordered. The facility failed to administer treatments as ordered for Resident #8. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 was admitted with a Stage I pressure sore record review revealed the area was not assessed weekly. Staging and Measurements of the wound were as follows: 5/5/13-sacrum- Stage I-11.9 cm (centimeters) x 9.9 cm; 5/13/13-sacrum- Stage I-12 cm x 11 cm; 6/9/13- the stage was determined to be SDTI (Staged Deep Tissue Injury) measuring 3.5 cm x 1.5cm; 6/16/13-sacrum- Stage II measuring 1.8 cm x 2.3 cm; 7/6/13-sacrum-unstageable-2.8cm x 3.8 cm x .7 cm; 7/6/13-Left buttock-acquired-unstageable-1.4 cm x 1.3 cm x .2 cm; 7/19/13-sacrum- Stage IV-4.2 cm x 4.8 cm x .7 cm-100% [MEDICATION NAME]/serous-tunneling and/or undermining; 7/19/13- left buttock-Stage IV-1.4 cm x 1.2 cm x .1 cm; 7/27/13-sacrum-Stage IV-4 x 4.5 x .7 cm-100% [MEDICATION NAME]/serous-tunneling and/or undermining; 7/27/13-left buttock-Stage IV-1.4 x 1.2 x .1 cm-100% [MEDICATION NAME]; 8/5/13-sacrum-Stage IV-4 x 4 x 1 cm-100% [MEDICATION NAME]/Serous-tunneling and/or undermining; 8/5/13- left buttock- Stage IV-1.6 x 1 x .1 cm-100% [MEDICATION NAME] 8/11/13-Sacrum-Stage IV-4 x 4 x 1 cm-100% [MEDICATION NAME]/serous-tunneling and/or undermining; 8/11/13-left buttock-Stage IV-1.6 x 1 x .2 cm-100% [MEDICATION NAME]; 8/21/13-Sacrum-Stage IV-6 x 4 x 2 cm-100% [MEDICATION NAME]/serosanguineous-tunneling and/or undermining; 9/2/13- Sacrum-Stage IV-6 x 4 x 1.8 cm-90% granulation/10% slough/serosanguineous-tunneling and/or undermining; 9/6/13-Sacrum - Stage IV-6 x 4 x 2 cm-90% granulation/10% slough/serosang… | 2016-10-01 |
| 7950 | 7950 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 323 | G | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, observation, and interviews, the facility failed to provide adequate supervision and implementation of functional devices and fall prevention measures to prevent accidents for two of three residents reviewed for falls. The facility failed to provide fall prevention interventions post hospitalization resulting in Resident #10 sustaining a second hip fracture. Although no significant changes were noted in the resident's mental status from date of discharge (7-23-13) to readmission (7-29-13), the amount of assistance required with activities of daily living increased, and the resident was at high risk for falls based on the facility's assessment, the facility failed to reinstate fall precautions upon readmission that were present prior to hospitalization . Resident # 2, with a history of falls had a non-functional pad alarm in place. The findings included: The facility admitted Resident #10 initially on 5-30-13 for short-term rehabilitation following a fall resulting in a right femoral fracture. [DIAGNOSES REDACTED]. Record review on 10-10-13 at 3:55 PM revealed that Resident # 10 was sent to the hospital on 7-23-13 and admitted for Acute Respiratory Failure secondary to Flash Pulmonary Edema. S/he was readmitted to the facility on [DATE]. Review of the 7-23-13 Discharge Minimum Data Set Assessment revealed that Resident #10 was discharged with return anticipated. The resident was noted with a short-term memory problem and signs and symptoms of delirium. S/he had fluctuating difficulty focusing attention, disorganized thinking, and altered level of consciousness. The resident exhibited wandering behavior 4-6 days during the look-back period. S/he required limited assistance with all activities of daily living and was frequently incontinent of bowel and bladder. Section J noted history of a fall since the prior assessment. Section N noted no psychoactive medications administered in… | 2016-10-01 |
| 7951 | 7951 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 325 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews, the facility failed to adequately monitor dietary intake and weights for two of two sampled residents reviewed for weight loss. The facility failed to consistently monitor the dietary intakes of Residents #7 and #10 who were identified with significant weight loss. The findings included: The facility admitted Resident #10 initially on 5-30-13 for short-term rehabilitation following a fall resulting in a right femoral fracture. [DIAGNOSES REDACTED]. Record review on 10-10-13 at 3:55 PM revealed that Resident #10 was sent to the hospital and admitted for Acute [MEDICAL CONDITION] secondary to Flash [MEDICAL CONDITIONS] on 7-23-13. S/he was readmitted to the facility on [DATE]. On 8-3-13, Resident #10 was hospitalized following a fall for treatment of [REDACTED]. S/he was readmitted on [DATE] and discharged home on 9-16-13. Review of weight records provided and verified by the DON on 10-11-13 at 4:30 PM revealed an admission weight of 159 pounds. Resident #10 weighed 150.6 pounds on 7-20-13, a loss of 8.4 pounds (5.6%) prior to hospital transfer for [MEDICAL CONDITION]. The readmission weight on 7-29-13 was 131 pounds (12.2%) and the 8-8-13 readmission weight was 130 pounds. The resident continued to lose weight until discharged on [DATE] at 117.3 pounds. No dietary interventions were put in place until 8-23-13 when Ensure Plus was provided with meals. Review of the Medication/Treatment Administration Records revealed there were no percentages of intake of the dietary supplement recorded. Review of the 6-5-13 Medical Nutritional Therapy (MNT) Assessment revealed an admission weight of 159 pounds (#). The resident was noted with a fluctuating appetite. Review of the 9-4-13 MNT (Medical Nutritional Therapy) Note revealed that the Registered Dietitian documented a significant w(eigh)t loss last month (22.2#=14.74%). Resident #10 went out to hospital on 7-23 and readmitt… | 2016-10-01 |
| 7952 | 7952 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 328 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to follow Physician's Orders related to oxygen (O2) therapy for one of two sampled residents reviewed on oxygen. There was no evidence that staff attempted to wean Resident #7 from oxygen dependency as ordered. The findings included: The facility admitted Resident #7 following a fall resulting in hospitalization for treatment of [REDACTED]. Additional [DIAGNOSES REDACTED]. Record review on 10-10-13 at 9:30 AM revealed 9-4-13 admission Physician' s Orders for O2 @ 2 L(iters)/ min(ute) with 02 sat(uration) q (every) shift. On 9-6-10, Physician's Orders were noted to Wean O2 NC (nasal cannula) for sat > 92%. Review of 9-13 Medication/Treatment Administration Records on 10-11-13 revealed no evidence that attempts had been made to wean Resident #7 off oxygen therapy. Oxygen was noted as administered at 2L/min at all times when documented. No evidence was found in the medical record that Physician's Orders were followed, though the resident's O2 sats were consistently greater than 92%. There was no indication that the infusion rate was ever decreased to evaluate resident tolerance. During an interview on 10-11-12 at 12:30 PM, the Director of Nurses verified the above information and stated that the order had not been addressed. S/he noted that Respiratory Therapy was shared with 2 other facilities and there was no record in the facility of the resident being seen. | 2016-10-01 |
| 7953 | 7953 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 329 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to monitor the blood pressure (BP) as needed for administration of medications as ordered for one of two sampled residents reviewed on PRN (as needed) antihypertensive medication. The facility failed to monitor the BP routinely for Resident #10 who was ordered on PRN antihypertensive medication. The findings included: The facility admitted Resident #10 initially on 5-30-13 for short-term rehabilitation following a fall resulting in a right femoral fracture. [DIAGNOSES REDACTED]. Record review on 10-10-13 at 3:55 PM revealed that Resident # 10 was sent to the hospital and admitted for Acute [MEDICAL CONDITION] secondary to Flash [MEDICAL CONDITIONS] on 7-23-13. S/he was readmitted to the facility on [DATE]. Record review on 10-10-13 at 4:25 PM revealed 6-17-13 physician's orders [REDACTED].> 180. [MEDICATION NAME] 25 mg was ordered daily on 6-24-13, increased to 50 mg daily on 6-27-13, and to 75 mg on 7-15-13. On 7-3-13, [MEDICATION NAME] 10 mg was added daily and the [MEDICATION NAME] PRN dosage was increased to 50 mg with the same parameters. On 7-29-13, upon readmission, [MEDICATION NAME] 10 mg was added daily and [MEDICATION NAME] 20 mg tablet was added twice daily. The PRN antihypertensive was changed to [MEDICATION NAME] 50 mg tablet for systolic BP > 140. Following hospitalization from ,[DATE] to 8-8-13, a physician's orders [REDACTED].> 180. After hospitalization from [DATE] to 8-8-13 for a second [MEDICAL CONDITION], the order for [MEDICATION NAME] 50 mg PO Q 8 PRN for SBP > 180 was reinstated. During an interview on 10-11-13, when asked how often the BP should be monitored with PRN antihypertensive orders as noted, the DON stated, Every 8 hours. Review of the Care Plan revealed a problem onset date of 6-12-13: (Resident #10) has a potential for complications related to [DIAGNOSES REDACTED]. Approaches included to monitor BP as ordered, … | 2016-10-01 |
| 7954 | 7954 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 333 | E | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to ensure that residents are free of any significant medication errors. Resident #4 had a medication ordered 12/12/13 that was never started. Resident #17 had a medication ordered 1/6/14 that was profiled on the medication administration record to start 1/16/14. Two of 9 residents reviewed for medication errors. The findings included: Review of Resident #17's medical record on 1/7/14 revealed Physician Telephone orders dated 1/6/14 [MEDICATION NAME] 875 BID (twice daily) #20 for raised [MEDICAL CONDITION] left thighand [MEDICATION NAME] powder to area between thighs bilaterally use powder QID (four times daily) x 10 d(ays) for yeast infection. Both orders were signed by the nurse on 1/6/14 at 8:00 PM. Review of the Medication Administration Record (MAR) for January 2014 revealed the order for [MEDICATION NAME] powder was profiled with a start date of 1/6/14 and was signed as administered on 1/6/14 at 9:00 PM and on 1/7/14 at 9:00 AM. The order on the Medication Administration Record was for [MEDICATION NAME] Powder to area between thighs bilaterally apply topically BID (twice daily) x 10 days. There was no clarification order or Nurses Note related to the discrepancy in administration times. Further review of the MAR for January 2014 revealed the order for [MEDICATION NAME] 875 MG PO BID x 10 days with a start date of 1/16/14. There was no clarification order or Nurses Note related to the discrepancy in start date. The medication had not been administered as of 1/7/14 at 2:55 PM. During interview with the surveyor on 1/7/14 at approximately 2:55 PM, the Director of Nurses (DON) stated that the yellow copy of the Physician's Telephone Orders are reviewed in morning meeting and checked to make sure they are profiled correctly. The DON stated that the nurse at night on 1/6/14 should have done a 24 hour chart check and noted the order for [MEDICATIO… | 2016-10-01 |
| 7955 | 7955 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 386 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the first revisit survey, based on record review and interviews, the facility failed to provide physician's review of MEDICATION ORDERS FOR [REDACTED]. The findings included: Review of Resident #4's medical record revealed the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #4 was noted with an order for [REDACTED].>Review of Resident #4's December 2013 MAR indicated [REDACTED]. The January 2014 MAR indicated [REDACTED]. The facility admitted resident #15 with [DIAGNOSES REDACTED]. Review of the resident's Physician Orders of 12/13/13 revealed an order for [REDACTED]. Review of the resident's MAR (Medication Administration Record) revealed the resident received the [MEDICATION NAME] in December on 12/15, 12/16/ 12/18, 12/19, 12/23, 12/24, 12/27, 12/28, 12/29/2013. In January the resident received the [MEDICATION NAME] on 1/1, 1/2, 1/3 and 1/7/2014. Review of the resident's bowel movement records revealed the resident had loose stools documented on 12/14, 12/20, 12/21, 12/22, 12/23, 12/24, 12/26, 12/27, 12/30, 12/31/2013; 1/1, 1/2, 1/4, 1/5, 1/6 and 1/7/2014. Review of the Physician's Visits dated 12/14/13, 12/16/13, 12/18/13, 12/23/13 and 1/2/14, included a medication review. On each visit [MEDICATION NAME] was listed as an active medication. The visits also stated the resident had [MEDICAL CONDITION]; was on [MEDICATION NAME] and isolation precautions. Review of the systems review on each visit included the Gastrointestinal system that stated, Not Present: Bowel changes, Constipation, Diarrhea, Indigestion, Nausea, Vomiting, Abdominal Pain, Dysphagia and Heartburn. The resident had a bowel infection that resulted in loose stools, but had an order for [REDACTED]. On 1/1/7/2014 at approximately 4:00 PM, the Nurse Practitioner (NP) was interviewed by the surveyor. The Nurse Practitioner stated that the resident's [MEDICATION NAME] was an oversight. Resident #16 was admitted to the facilit… | 2016-10-01 |
| 7956 | 7956 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 425 | E | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. Resident #18 and #16's medications were not monitored for interactions. Two of 9 residents reviewed for pharmacy medication review The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Physician order [REDACTED]. Review of Resident #16's Hospital Discharge Summary Addendum dated 12/19/13 revealed Because of her/him being started on Cipro, it has a contraindication with her/his tizanidine, so the tizanidine will be switched to Flexeril 5 - 10 milligrams by mouth every 8 hours as needed for spasms . The Discharge Medications were listed as: 1. Cefepime 2 g(ram) intravenous every 12 hours (h) for 6 weeks. 2. Cipro 500 milligrams by mouth twice a day for 6 weeks plus. 3. The tizanidine has been discontinued and s/he will be on Flexeril 5-10 milligrams by mouth every 8 hours as needed for spasms. Review of the Physician's Telephone orders revealed an order on 12/23/13 Cefepime 2 gms IV Q 12 h x 6 week. Stop on 2/4/14. Cipro 500 mg 1 tab PO (mouth) BID (twice a day) for 6 weeks. Stop on 2/4/14. There were no orders related to the resident's tizanidine order. Review of Resident #16's Medication Administration Records for December 2013 and January 2014 revealed the resident continued to receive Cipro and tizanidine 12/23/13 - 1/7/14. In an interview with the surveyor on 1/7/14 at approximately 10:10 AM, the Director of Nurses (DON) stated that they called the hospital to find out why Resident #16 had a PICC line and were told that the resident should be on IV (intravenous) antibiotics. The hospital faxed over the Discharge Summary Addendum that included information related to the IV antibiotics on 12/23/13. During interview at 10:30 AM the DON confirmed that the tizanidine should have been discontinued… | 2016-10-01 |
| 7957 | 7957 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 441 | D | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to obtain a stool specimen for clostridium difficile (C-diff) toxin as ordered for one of three residents reviewed for implementation of transmission based precautions. No stool specimen was obtained as ordered for Resident #12 who was placed on contact precautions for symptoms of[DIAGNOSES REDACTED]. In addition, based on observations, interviews, and review of the facility policy entitled Perineal Care (revised 10-10), the facility failed to follow a technique to maintain infection control for two of three residents observed for provision of incontinent/perineal care (Residents #2 and #6). The findings included: The facility admitted Resident #12 post hospitalization for treatment of [REDACTED]. Review of the 8-28-13 Minimum Data Set Assessment revealed that the resident had both short- and long-term memory impairment. S/he was totally dependent for bed mobility, transfers, and locomotion and was frequently incontinent of bowel and bladder. Review of the Nurse Practitioner's (NP) 9-2-13 Progress Note revealed that on 9-1-13, Resident #12 had some smelly diarrhea and stool sample has been sent .Verbal Order .Obtain Stool Specimen. No further Physician's Progress Notes were present in the record or available to surveyors. On 10-12-13 at 4 PM, the Director of Nurses provided a copy of a 9-5-13 Progress note stating that the resident was off isolation and diarrhea was no longer present. Record review on 10-12-13 at 10 AM revealed an 8-29-13 Physician's Order to obtain a stool specimen. No laboratory report of the results could be located. On 8-30-13, there was an order to place the resident on contact isolation. Review of the Care Plan on 10-12-13 at approximately 10 AM revealed a problem onset date of 8-30-13 for Resident has positive result for clostridium difficile culture in their stool. resolved 9-5-13. During an interview on 10-12-13 at 1:05… | 2016-10-01 |
| 7958 | 7958 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 502 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to obtain laboratory services to meet the needs of its residents. Resident #4 had an order for [REDACTED]. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed an order dated 12/9/13 for weekly H(emoglobin) & H(ematocrit) on Mondays x 4 weeks. Review of the medical record revealed a lab results report dated 12/9/13 for hemoglobin 9.6 ( normal values 11.2 - 15.7) grams/desiliters and hematocrit 30.4 (normal values 43.1 - 44.9) percent. There were no other lab result reports for hemoglobin and hematocrit. Review of the Nurse Practitioner Progress Report dated 11/22/13 indicated patient sent to the hospital for HGB (hemoglobin) 5.0. Stable at time of transfer Resident #4 returned from the hospital on [DATE]. In an interview with the surveyor on 1/8/14 at approximately 1:55 PM, the Director of Nursing (DON) stated that the hemoglobin and hematocrit ordered for 12/16/13, 12/23/13 and 12/30/13 were not drawn. The DON stated that the labs were not entered into the computer to be drawn. The DON stated that the ward secretary receives the lab orders and puts them in the computer. The DON checks the yellow copy of the lab to make sure it's entered. The DON stated that s/he did not check the lab order for Resident #4. | 2016-10-01 |
| 7959 | 7959 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 507 | D | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews, the facility failed to have results of physician-ordered laboratory (lab) services available for review for 2 of 3 residents reviewed for laboratory services. Resident #12 and Resident #7 had lab results that were not available on the medical record for review for compliance with physician's orders [REDACTED]. The findings included: The facility admitted Resident #12 post hospitalization for treatment of [REDACTED]. Record review on 10-12-13 at 10 AM revealed physician's orders [REDACTED]. No laboratory reports of the results could be located in the medical record. On 10-12-13 at 10:47 AM, the Director of Nurses verified that there were no lab results on the medical record. S/he provided copies of lab reports at 11 AM, but was unable to verify if the physician had been made aware of the results. During an interview on 10-12-13 at 1:05 PM, the Corporate Consultant stated no stool specimen had been sent to the laboratory to check for [MEDICAL CONDITION]. The resident had been placed on isolation precautions because of loose stools, but when staff went to obtain the specimen, s/he became asymptomatic. During an interview on 10-12-13 at approximately 4 PM, the Director of Nurses also stated that there was no stool sample sent after the order was received because the resident was asymptomatic. The facility admitted Resident #7 following a fall resulting in hospitalization for treatment of [REDACTED]. Additional [DIAGNOSES REDACTED]. Record review on 10-10-13 at approximately 9:30 AM revealed a 9-20-13 physician's orders [REDACTED].([MEDICAL CONDITION]). The reported results could not be located in the medical record. During an interview on 10-10-13, the Corporate Consultant stated that a copy had been provided to surveyors on 10-9-13. During an interview on 10-11-13, the Director of Nursing provided copies of the laboratory reports ordered on 9-20-13 and verified that … | 2016-10-01 |
| 7960 | 7960 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 514 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 7 of 12 residents reviewed. Resident #2, 3, 7, 8, 10 and 11 had omissions on the Medication and/or Treatment Records. Resident #3 had discrepancies in the medical record related to having a pressure sore. Resident #6 had a discrepancy related to an ostomy. Nurses failed to document discharge notes for Resident #10 for 7/23/13 and 8/3/13. Resident #10 also had a discrepancy in date/time of an incident/fall. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/10/13 revealed the following omissions on the Medication and/or Treatment Records: August 2013 Treatment Record- 1) Floor mat at bedside -8/12/13; 2) Pad alarm to bed-8/12/13; 3) Cleanse ST(skin tear) to left forearm with NS(Normal Saline), pat dry, apply TAO(Triple Antibiotic Ointment) and cover with [MEDICATION NAME] Q(every)D(day)-8/2, 3, 6, 7, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 24, 27,28, 29, 30, and 31/13. 4) Clean area to sacrum with NS and pat dry. Apply Exuderm, change q3days and prn(as needed)-8/11/13, 8/14/13, 8/17/13, 8/23/13, and 8/29/13. 5) Clean area to left pointer finger with NS and pat dry. Apply TAO and cover with bandaid. Change QD(every day) and prn-8/3, 4, 7, 11, 12, 13, 14, 16, 17, 19, 21, 22, 23, 25, 28, 29, 30, and 31/13. 6) Clean PEG(Percutaneus [MEDICAL CONDITION] Gastrostomy) tube site with NS, apply dry dressing QD-8/3, 4, 6, 7, 12, 13, 14, 16, 17, 19, 21, 22, 23, 25, 29, 30, and 31/13. 7) Skin Prep to bilateral heels q shift-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13. 8) Float heels while in bed-8/1, 3, 4, 7, 12, 16, 17, 19, 21, 22, 25, 28-31/13. 9) Tab alarm for safety-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13. 10)… | 2016-10-01 |
| 8349 | 8349 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 153 | D | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on closed record review and interview, the facility failed to provide the legal representative for Resident #1 a copy of the resident's medical record. The facility failed to provide the copies of the medical record per the federal guidelines within 48 hours after a written request by the legal representative. The findings included: Review of the Agape Senior Authorization for Release of Protected Health Information revealed Resident #1's Power of Attorney completed the request on [DATE]. Review of the medical records request log revealed the request for Resident #1's medical record was received on [DATE]. Review of the Medical Record Copying Fee Sheet for Resident #1's medical record revealed it was completed [DATE]. Review of the Agape Nursing and Rehabilitation Center Contract signed by Resident #1's Power of Attorney on [DATE] revealed Section V (d) .Copies of medical records will be released to the Resident or Legal Representative within two (2) working days of the written request During interview on [DATE] the facility Administrator stated that Resident #1's Power of Attorney provided the written request for the medical record on [DATE] after Resident #1 expired. Review of Resident #'1's Daily Skilled Nurse's Note dated [DATE] revealed s/he expired at 6:55 PM. | 2016-05-01 |
| 8350 | 8350 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 155 | E | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to provide the resident the right to formulate an advance directive. Resident's #1, #2 and #4 was not provided the right to formulate his/her advance directive on admission to the facility. The findings included: Resident #1 was admitted to the faciilty on 3/4/13. Review of the Daily Skilled Nurse's Note dated 3/4/13 at 4:30 PM revealed the resident arrived at the facility and was alert and oriented x 3. Review of the Authorization for Allow Natural Death Patient Without Ability to Consent was signed by Resident #1's Power Of Attorney on 3/4/13. The form was signed by the resident's Attending Physician on 3/11/13 and by the Concurring Physician on 3/13/13. Resident #1 was sent out and admitted to the hospital 3/12/13 and returned to the facility 3/16/13. Further review of the closed medical record revealed an order dated 3/4/13 DNR (Do Not Resucitate). The order was signed by the resident's Attending Physician on 3/11/13. During interview on 4/30/13 at approximately 2:30 pm the Admissions Coordinator stated that Resident #1 was alert and oriented when s/he was admitted to the facility on [DATE]. During interview on 5/1/13 at approximately 2:30 pm the Assistant Director of Nursing (ADON) stated that s/he completed the Authorization for Allow Natural Death Patient Without Ability to Consent for Resident #1. The ADON stated that Resident #1 was alert and oriented to self only at admssion. The ADON stated that two Physician signatures are required for a resident without the ability to consent. The ADON confirmed that the DNR order was written on 3/4/13 and signed by the Physician on 3/11/13. The ADON confirmed that the concurring Physician signature was not received until 3/13/13. The DNR order was obtained at the time of admission, before the resident was determined to not have the ability to consent by two physicians. The resident was assessed to … | 2016-05-01 |
| 8351 | 8351 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 157 | D | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to immediately inform the resident's legal representative of a change in the resident's status. Someone other than Resident #1's legal representative was not notified of changes in physician's orders [REDACTED]. The findings included: Review of Resident #1's medical record revealed the Physician telephone orders dated 3/8/13, 3/11/13, and 3/19/13 indicated that someone other than the responsible party was notified of the new orders. Further review of Resident #1's medical record revealed the Physician telephone orders dated 3/18/13, 3/19/13 and 3/22/13 indicated that no one was notified about the new orders. Review of the Daily Skilled Nurse's Notes dated 3/18/13 and 3/19/13 revealed the following: 3/18/13 the following order was documented in the Nurse's Notes, give 2 L(iters) NS (normal saline) at 100 ml (milliliters)/hr (hour). May d/c (discharge) INT after. Hold [MEDICATION NAME] until levels are 3/19/13 7 a - 7 p indicated res(ident) cond(ition) unstable @ this time. Very lethargic and not responding much this am. This PM, much more responsive but refusing meds and blood sugar finger sticks, very irritable. Vanco(mycin) on hold @ this time. IV fluid bolus @ 100 ml/ hr x 2 bags. Will cont(inue) to monitor . bed wedge to float heels while in bed q(every) shift. There was no indication that the responsible party was contacted about the resident's change in condition and new orders. In an interview with the surveyor on 4/30/13 at approximately 2:30 PM the Admissions Coordinator and the Administrator stated that there was an error with who the responsible party was when Resident #1 was initially admitted . The resident's Power of Attorney was in the facility on the day of admission and the error was corrected and that the facility had not contacted anyone except the Power of Attorney regarding Resident #1's health. | 2016-05-01 |
| 8352 | 8352 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 201 | D | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview the facility failed to provide evidence of the necessity for the transfer/discharge of Resident #15, 1 of 7 discharged residents reviewed. The resident was discharged from the facility on 3/20/13 without evidence of need and/or cause. The findings included: Resident #15 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the closed medical record revealed the nurse's notes from 3/9/13 through 3/18/13 documented that the resident was stable. The nurse's note of 3/20/13 at 2:00 PM stated, Stable, denies needs @ (at) this time; family at bedside. 3/20/13 at 3:30 PM stated, Family requesting pt (patient) be sent to ____ (hospital) ER (emergency room ) for eval (evaluation). EMS (Emergency Medical Services) on scene to transport. There was no other documentation in the record indicative of the resident being medically unstable and requiring emergency services. The Director of Nurses (DON) was interviewed by the surveyor on 5/1/13 regarding the resident's transfer/discharge. The DON stated the family did not feel s/he was being treated for [REDACTED]. There was no indication the resident had any medical need requiring transfer to the hospital. | 2016-05-01 |
| 8353 | 8353 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 225 | E | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interview and information provided by the facility, the facility failed to conduct thorough investigations and report allegations of abuse/neglect to the state agencies for 3 of 5 allegations of abuse/neglect. Resident's #4, #5 and #7 filed grievances with the facility for allegations of neglect. The facility did not obtain witness statements or report allegations to the stated agencies of Certification or the Ombudsman. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the medical record revealed a nurse's note dated 4/8/2013 at 2:00 AM. Resident noted to be agitated and upset. Family in room at bedside B/P (blood pressure) 230/119. MD (Medical Doctor) and family notified. Obtained order to administer 0.1 mg (milligrams) [MEDICATION NAME] x 1 dose. Family refused and became irate. Family member yelling and cussing at staff. Family member demanded that the resident be sent to ER (emergency room ). MD notified, order obtained. Sent to ER for further evaluation. Review of the facility's grievances revealed a grievance filed by Resident #4's family on 4/9/13, the day after the resident was sent to the ER. The grievance listed concerns which included, but were not limited to: 1. On Easter Sunday the family brought the resident a Sunday outfit to wear at 8:00 AM and left it because the resident was asleep. The family member returned at 6 PM and found the resident sitting at the entrance to dining room with breasts exposed. The resident told the family s/he had been sitting in urine and feces since 1:00 PM. (5 hours) 2. On 4/8/13 the facility called the family member at approximately 1:00 AM informing family member that the resident was upset because someone had stolen her money. The family member stated the resident was upset over her money being gone, eyes were glassy and s/he was breathing hard. I asked nurse to take her blood pressure 23… | 2016-05-01 |
| 8354 | 8354 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 226 | E | 1 | 0 | G3XH11 | On the days of the complaint inspection, based on facility files and interviews, the facility failed to follow their policy on abuse/neglect for 3 of 7 sampled residents on the transitional unit. The facility failed to conduct a thorough investigation, to obtain written statements and failed to report allegations of abuse/neglect to state agencies. The findings included: Cross-refer to F-225 Investigating and Reporting allegations of abuse neglect. Resident #4's family reported allegations of misappropriation (stolen money) and neglect (not being changed; Resident #5 family reported concerns related to incontinent care; Resident #7's family alleged neglect related to the failure of the facility to provide incontinent care for approximately 4 1/2 hours. Review of the facility Abuse Policy and Procedure (P&P) revealed the Policy stated, This facility does not tolerate any forms of mistreatment, neglect, abuse or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical, and/or mental abuse, corporal punishment, and involuntary seclusion. This policy is adhered to whenever an incident or suspected incident of verbal or physical abuse, neglect, or mistreatment/misappropriation of resident property (or other reasonable suspicion of a crime) has occurred. The P&P defined Neglect. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Under the title Procedure the section on reporting stated, C. The Administrator or designee immediately begins investigating the allegation(s). The Department of Health and Environmental Control and the ombudsman are also notified, as appropriate. The initial report must be phoned or faxed in within 24 hours. Under the Section entitled Investigations: Section B. Interviews will be conducted with all pertinent parties and written and signed statements obtained from those persons, who saw or heard information pertinent to the incident. If residents are able to tell you what happ… | 2016-05-01 |
| 8355 | 8355 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 252 | D | 1 | 0 | G3XH11 | On the days of the complaint inspection, based on observation, the facility failed to provide a clean homelike environment. Strong odors were noted on all three halls of the transitional care unit. The findings included: During initial tour of the facility on 4/29/13 at approximately 4:30 PM, surveyors noted strong odors on all three units of the transitional care unit. The surveyor noted a strong urine odor in room 204 on 4/29/13 at approximately 4:50 PM and again at approximately 5:50 PM. At the time of the 5:50 PM observation the surveyor noted that both residents were in their room eating dinner and a visitor was in the room. The door to the bathroom was closed and a strong odor was noted in the resident's room the surveyor asked if s/he could open the bathroom door, urine was seen in the commode and a yellow stained cloth on the floor beside the commode in the bathroom. | 2016-05-01 |
| 8356 | 8356 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 281 | E | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, interview, and review of the professional resource, Perry/Potter Clinical Nursing Skills and Techniques 7th Edition, the facility failed to follow professional standards of nursing practice related to documentation of the completion of skin/wound assessments and the medical need for the hospital transfer for Resident #15; failed to provide clear, concise documentation of code status for Residents #2 and #4 (3 of 7 residents sampled for professional standards). The findings included: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nurse's notes dated 3/8/13 at 3:45 PM revealed, Small amount of bogginess to R (right) heel and bilateral hand skin tears. Nurse's notes from 3/9/13 through 3/18/13 stated resident was stable. 3/19/13 The resident complained of mild back pain. On 3/20/13 at 2:00 PM the resident was documented to be stable. At 3:30 PM, Family requesting pt (patient) be sent to ______(hospital) ER (emergency room ) for eval (evaluation). EMS (emergency medical service) on Scene to transport. There was no documentation/evidence of the condition of the resident. No vital signs or nursing assessment to indicated the resident's need for emergent medical care. There was no documentation of a change in the resident's condition. In addition, the resident's admission body assessment revealed that the resident had a red blanchable area on his/her sacrum area. The body assessment also identified the right heel as a stage I (pressure sore) boggy area. The 3/15/13 Weekly Wound assessment continued to show a red blanchable area on the sacrum. The Stage I on the right heel was documented to be 7 X 6 centimeters (cms). The 3/19/13 wound assessment documented the red blanchable area on the sacrum; the right heel was documented as a Stage I measuring 6.2 X 5.4 cms. A new area on the left heel was documented as pink but blanchable. Th… | 2016-05-01 |
| 8357 | 8357 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 514 | E | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews and interviews the facility failed to keep complete accurate records for 3 of 7 residents reviewed for accurate medical records. (Resident #15, #2 and #4). The findings included: Cross refer to F281, Standards of Practice related to documentation Resident #15 was sent to the emergency room . There was no documentation of the residents condition, assessment of a change of condition or the medical need for a transfer. The resident did not have complete wound/skin documentation. Review of the medical record revealed that the documentation of the sacral area wound was not adequate to determine if the wound had worsened or healed. Resident #2 had both Patient with Ability to Consent and Patient Without Ability to Consent forms on her/his medical record. Both were signed on the same days by the resident representative and the Physicians. A physician's orders [REDACTED]. Resident #4 had a physician's orders [REDACTED]. The resident's Patient Without Ability Consent form was not signed by the physician's until 4/1/13 and 4/5/13. | 2016-05-01 |
| 8358 | 8358 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-30 | 241 | E | 1 | 0 | FG7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews and interviews, the facility staff failed to provide care in a manner that maintained and enhanced dignity for 3 of 5 sampled residents (Residents #2, #3, and #4) and for 1 of 4 randomly selected residents listed as interviewable by the facility (Resident D). The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 5/21/13 revealed Resident #4 had a Brief Interview for Mental Status score of 15, indicating s/he had been cognitively intact at the time of the assessment. According to the assessment, the resident required extensive assistance with two person physical assistance for transfers and toileting. Review of the 5/8/13 hospital Discharge Summary revealed information that Resident #4 .is receiving physical therapy twice daily. Today s/he was ambulatory with physical therapy for 14 feet x 2. I observed the patient with standby assistance to the restroom earlier and s/he was ambulating well. Weightbearing as tolerated with the rolling walker . Orders on discharge include physical therapy, ambulate weightbearing as tolerated with the rolling walker . Review of a Bladder Re-Training assessment dated [DATE] revealed Resident #4 was continent. Review of the Interim (Admission) Care Plan revealed an entry for Alteration in ADL (Activities of Daily Living) ability, Requires assist with .ambulation, .transfer . toilet use. The goal was that Resident will have needs met and included interventions that had been checked, such as .use adaptive equipment as ordered . During a phone interview on 5/28/13 at 4:00 PM, Resident #4 reported that on May 18, 2013 (Saturday night a week ago), s/he needed assistance to the bathroom and a Certified Nursing Assistant (CNA) came in and said that s/he would not be able to help, and that the resident would have to wear a diaper since it wa… | 2016-05-01 |
| 8359 | 8359 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-30 | 325 | E | 1 | 0 | FG7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observation, and interviews, the facility failed to assess the nutritional needs of 3 of 11 residents with pressure sores. Resident #1 had numerous pressure sores with no assessment of the resident's nutritional needs to promote healing of the wounds. Resident #5 developed pressure sores in the facility and did not have an assessment of her/his nutritional needs to promote healing. Resident #7 was admitted with pressure sores and did not have a timely nutritional assessment. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the hospital Operative Report dated March 19, 2013 revealed under operative findings; S/he had a blister on her heel as well as a blister on the lateral . An Ace blister on the dorsum of the medial foot . I think these are all secondary to pressure from her [DIAGNOSES REDACTED] in the splint implants. The Initial Body assessment dated [DATE] indicated the right foot and leg to mid calf was in a soft cast. Nurse's Note for 3/27/13, 7 A--7 P stated, Resident had blood soaking through soft cast. Contacted orthopaedic surgeon for orders on how to change or add dressing to help with drainage. Surgeon appt. (appointment) made for today. Resident returned with plaster cast. There was no mention of the residents blisters or skin problems under the cast. An Orthopaedic Consultation dated 4/17/13 stated the fractures were not healed. Needs wound care for right heel ulcer (and left medial malleolus). A Pre-[MEDICATION NAME] was obtained on 4/24/13 to check the residents protein. The pre-[MEDICATION NAME] level was low at 6.2 milligrams per deciliter. Normal range was 17.0-34.0 mg/dl. Review of the body assessment of 5/19/13 revealed the resident had six (6) pressure areas in the area covered with a cast and over areas of hardware used to repair the residents fractures of her/his right leg. The wound measurements, length by wid… | 2016-05-01 |
| 8360 | 8360 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-30 | 328 | E | 1 | 0 | FG7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews and interviews, the facility failed to provide appropriate care and services related to respiratory needs for Residents #2, #16, and #18, 3 of 4 sampled residents reviewed with [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) or [MEDICAL CONDITION] (Continuous Positive Airway Pressure). Resident #2 did not receive clarification of orders related to Oxygen and [MEDICAL CONDITION] on admission. There was no documentation in the record to indicate the nursing staff clarified with the Physician as to whether Resident #2 required an order for [REDACTED].#2's Care Plan had not been updated relative to his/her removal of the [MEDICAL CONDITION] mask. Resident #2 had nursing documentation dated 5/19/13 that was either unclear and/or had nursing assessment information missing related to a change in condition. There was no documentation provided that the nursing staff had been trained in the use and operation of [MEDICAL CONDITION]/[MEDICAL CONDITION] equipment and signs/symptoms of complications. There was no documentation provided that Respiratory Therapy was monitoring Resident #2's response to therapy or that RT was ensuring proper use of the [MEDICAL CONDITION] by the resident and nursing staff. Residents #16 and #18 did not have documentation in the record related to the administration of [MEDICAL CONDITION] at bedtime. Their Care Plans had not been updated related to the [MEDICAL CONDITION]. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 5/14/13 revealed a Brief Interview for Mental Status score of 15, which indicated Resident #2 was cognitively intact at the time of the assessment. Review of the hospital Discharge Summary dated 5/7/13 revealed a Brief History and Clinical Course which documented the resident as having 2-3 weeks of lethargy. According … | 2016-05-01 |
| 8361 | 8361 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-30 | 425 | D | 1 | 0 | FG7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews, and review of information provided by the facility, the facility's pharmacy failed to provide ordered medication for Resident #2, one of three sampled residents reviewed for medication administration. Resident #2 did not receive ordered Phentermine for 6 days. The resident's Physician failed to address timely the Pharmacist's recommendation to discontinue the Phentermine. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review on 5/28/13 at 2:25 PM of the hospital Discharge Summary for Resident #2 dated 5/7/13 revealed Transfer Medications that included Phentermine 37.5 milligrams every morning before breakfast. Further review revealed this medication had been transcribed onto the facility's cumulative Admission Physician order [REDACTED]. Review of the Medication Record for May 2013 revealed an entry for Phentermine 37.5 mg (milligram) Capsule PO (By Mouth) Daily Before Breakfast . (Start 5/7/13, Discontinue 5/17/13). According to the record, the medication had not been given as ordered because it was not available. The Medication Record revealed documentation that the medication Phentermine had not been initialed as having been given on 5/8/13, 5/9/13, and 5/10/13 (due to not having received the medication from the pharmacy or the medication being enroute). The medication had been initialed as having been given on 5/11/13. However, according to Medication Record documentation, the Phentermine had not been administered on 5/12/13 and 5/13/13; with the 5/13/13 documentation stating the medication would not be available from the pharmacy until 5/14/13. The Medication Record revealed documentation that the Phentermine had been administered as ordered on [DATE], 5/15/13, and 5/16/13. On 5/17/13, it was documented that Resident #2 refused the Phentermine and a Physician's Telephone Order dated 5/17/13, revealed an entry to D/C (Disconti… | 2016-05-01 |
| 9114 | 9114 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-09-14 | 356 | C | 0 | 1 | YQ1X11 | On the days of the survey, based on random observation, review of posting documentation for 6 months, and interview, the facility had no documentation to show that the staffing hours and census had been posted per regulatory requirement. The findings included: On initial tour 9/13/11 at 6:45 AM, an observation was made of the facility staffing sheet and census sheet which was dated 9/7/11 and posted near the nurses station on the Transition Rehab(iltation) Center. A request was made for copies of the daily nursing staff postings for the prior 6 months. Review of these posting sheets revealed the following: In March 2011, 17 days were posted out of 31 days; April-11 days were posted out of 30 days; May - 14 days were posted out of 31 days; June -1 day was posted out of 30 days; July - 4 days were posted out of 31 days; August - 1 day was posted out of 31 days; and September only 6 days had been posted out of 13 days. During an interview with the DON (Director of Nursing) on 9/14/11 at 11:15 AM, she stated she would look on the other unit for additional documentation. A follow-up with the DON revealed that she had found multiple days missing were also missing on the other unit. She confirmed that the facility could not provide documentation that the postings had been done daily as required. | 2015-08-01 |
| 9115 | 9115 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-09-14 | 332 | E | 0 | 1 | YQ1X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, review of the facility provided policy for "Eye Administration" and interview, the facility failed to ensure that it was free of medication error rate of five (5) percent or greater. The medication error rate was 10%. There were 4 errors out of 40 opportunities for error. The findings included: Error #1: On 9/13/2011 at 9:00am, during observation of the medication pass on the Comprehensive Care Unit (CCU), Registered Nurse (RN) #1, was observed to instill two (2) drops of [MEDICATION NAME] Ophthalmic eye drops into the left eye (OS) of Resident A back to back. The Drug Facts and Comparisons book (updated monthly), page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "If multiple drop therapy is indicated, the best interval between drops is five (5) minutes....This ensures that the first drop is not flushed away by the second or that the second is not diluted by the first". During review of the "Eye Administration" policy on 9/13/2011 at 11:50am, it states "Wait 10-15 minutes between administrations of different types of eye drops to same eye". During an interview on 9/13/11 at 2:40pm, RN #1 confirmed that she did not think that she had to wait between eye drops since it was the same medication. RN #1 stated, it was her mistake and she would find out what was the correct administration timing between each eye drop administration. Error #2: On 9/13/2011 at 9:00am, during observation of the medication pass on the Comprehensive Care Unit (CCU), RN #1 was observed to instill two drops of [MEDICATION NAME] Ophthalmic Suspension into both eyes (OU) of Resident A without shaking the bottle prior to administration. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steriods) by shaking to provide an accurate dosage of drug". During an inte… | 2015-08-01 |
| 9116 | 9116 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-09-14 | 425 | D | 0 | 1 | YQ1X11 | On the days of survey, based on observation and interview, the facility failed to ensure that one (1) bottle of Diary Digestive Supplement located in one (1) of two (2) medication rooms were not expired. The findings included: On 9/13/2011, at 2:00pm, upon inspection of the Comprehensive Care Unit (CCU) medication room, revealed one (1) unopened bottle of Dairy Digestive Supplement, #60 caplets, with an manufactured expiration date of 04/11/2011 listed on the bottle label. The yellow, Agape Pharmacy label, dated 7/26/2011 with a expiration date of 7/25/2011, was attached to the bottle. During an interview on 9/13/2011 at 2:30pm with the Director of Nursing (DON), she revealed that she was responsible for checking incoming medications and expired products. The DON confirmed that the Assistant Director of Nursing (ADON) and the Corporate Compliance Officer also "comes through occasionally" to check the medication rooms. The DON also stated the Pharmacist comes once a month and she thinks they check the medication rooms at that time, but she was not completely sure. | 2015-08-01 |
| 9117 | 9117 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-09-14 | 371 | F | 0 | 1 | YQ1X11 | On the days of the survey, based on observation and interview, the facility failed to store and prepare food under sanitary conditions as evidenced by the walk-in freezer floor in the main kitchen contained debris; the hood filters had an accumulation of grease, dust, and paper; and there were unlabeled items in the TCU (transitional care unit) kitchen freezer. The findings included: Observations on 9/13/11 at approximately 6:50am revealed in the main kitchen the hood filters had a heavy accumulation of grease, dust, and a triangular shaped piece of paper sticking to a filter over the ovens. The floor of the walk-in freezer had an accumulation of paper debris, food particles, and Tater Tots strewn on the floor, between the slats of a pallet, and under the shelving. The freezer in the TCU kitchen had 2 bags of what appeared to be cookie dough which was not labeled. Observations in the main kitchen on 9/14/11 at approximately 3:30pm with the Dietary Manager present revealed the hood filters continued to have an accumulation of grease, dust, and a piece of paper on the filters. When asked how often the filters are cleaned the Dietary Manager stated the filters were cleaned by an outside company which last cleaned the hood and filters in June of 2011. When asked if the facility staff cleaned the filters themselves in between the cleanings by the outside company, he stated no. The walk-in freezer continued to have an accumulation of paper and food particles under the shelving. Observations on 9/14/11 revealed the continued presence of 2 unlabeled bags of cookie dough. Interview with the Registered Dietitian at approximately 2:10pm indicated that the unlabeled bags in the TCU kitchen freezer were not part of food service inventory but that facility staff have been instructed to label any food items put into the freezer. | 2015-08-01 |
| 9118 | 9118 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-09-14 | 456 | E | 0 | 1 | YQ1X11 | On the days of the survey, based on observation and interview, the facility failed to maintain mechanical, electrical equipment in a safe operating condition. A clothes dryer in the laundry room was observed with a build up of lint and the exhaust vent was open to the air causing an additional build up of lint on the back of the dryer. The findings included: During observation of the laundry room on the Convalescent Care Unit on 09/13/2011 at 10:20 AM, the dryer had a thick sheet of lint on the filter and on the sides of the lint compartment. Also, the exhaust vent was open to the air on the inside of the laundry room and there was lint built up on the dryer electrical cord and the back of the dryer. During an interview on 09/13/2011 at 10:30 am, the Housekeeping/ Laundry Manager verified the presence of the lint build up and the open exhaust vent. | 2015-08-01 |
| 9119 | 9119 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 502 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to obtain laboratory services to meet the needs of its residents. Resident #4 had an order for [REDACTED]. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed an order dated 12/9/13 for "weekly H(emoglobin) & H(ematocrit) on Mondays x 4 weeks". Review of the medical record revealed a lab results report dated 12/9/13 for hemoglobin 9.6 ( normal values 11.2 - 15.7) grams/desiliters and hematocrit 30.4 (normal values 43.1 - 44.9) percent. There were no other lab result reports for hemoglobin and hematocrit. Review of the Nurse Practitioner Progress Report dated 11/22/13 indicated "patient sent to the hospital for HGB (hemoglobin) 5.0. Stable at time of transfer.." Resident #4 returned from the hospital on [DATE]. In an interview with the surveyor on 1/8/14 at approximately 1:55 PM, the Director of Nursing (DON) stated that the hemoglobin and hematocrit ordered for 12/16/13, 12/23/13 and 12/30/13 were not drawn. The DON stated that the labs were not entered into the computer to be drawn. The DON stated that the ward secretary receives the lab orders and puts them in the computer. The DON checks the yellow copy of the lab to make sure it's entered. The DON stated that s/he did not check the lab order for Resident #4. | 2015-08-01 |
| 9120 | 9120 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 386 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the first revisit survey, based on record review and interviews, the facility failed to provide physician's review of MEDICATION ORDERS FOR [REDACTED]. The findings included: Review of Resident #4's medical record revealed the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #4 was noted with an order for [REDACTED]. Review of Resident #4's December 2013 MAR indicated [REDACTED]. The January 2014 MAR indicated [REDACTED]. The facility admitted resident #15 with [DIAGNOSES REDACTED]. Review of the resident's Physician Orders of 12/13/13 revealed an order for [REDACTED]. Review of the resident's MAR (Medication Administration Record) revealed the resident received the [MEDICATION NAME] in December on 12/15, 12/16/ 12/18, 12/19, 12/23, 12/24, 12/27, 12/28, 12/29/2013. In January the resident received the [MEDICATION NAME] on 1/1, 1/2, 1/3 and 1/7/2014. Review of the resident's bowel movement records revealed the resident had loose stools documented on 12/14, 12/20, 12/21, 12/22, 12/23, 12/24, 12/26, 12/27, 12/30, 12/31/2013; 1/1, 1/2, 1/4, 1/5, 1/6 and 1/7/2014. Review of the Physician's Visits dated 12/14/13, 12/16/13, 12/18/13, 12/23/13 and 1/2/14, included a medication review. On each visit [MEDICATION NAME] was listed as an active medication. The visits also stated the resident had [MEDICAL CONDITION]; was on [MEDICATION NAME] and isolation precautions. Review of the systems review on each visit included the Gastrointestinal system that stated, "Not Present: Bowel changes, Constipation, Diarrhea, Indigestion, Nausea, Vomiting, Abdominal Pain, Dysphagia and Heartburn". The resident had a bowel infection that resulted in loose stools, but had an order for [REDACTED]. On 1/1/7/2014 at approximately 4:00 PM, the Nurse Practitioner (NP) was interviewed by the surveyor. The Nurse Practitioner stated that the resident's [MEDICATION NAME] was an "oversight". Resident #16 was admitted to the fac… | 2015-08-01 |
| 9121 | 9121 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 425 | E | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. Resident #18 and #16's medications were not monitored for interactions. Two of 9 residents reviewed for pharmacy medication review The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Physician order [REDACTED]. Review of Resident #16's Hospital Discharge Summary Addendum dated 12/19/13 revealed "..Because of her/him being started on Cipro, it has a contraindication with her/his tizanidine, so the tizanidine will be switched to Flexeril 5 - 10 milligrams by mouth every 8 hours as needed for spasms...". The Discharge Medications were listed as: "1. Cefepime 2 g(ram) intravenous every 12 hours (h) for 6 weeks. 2. Cipro 500 milligrams by mouth twice a day for 6 weeks plus. 3. The tizanidine has been discontinued and s/he will be on Flexeril 5-10 milligrams by mouth every 8 hours as needed for spasms." Review of the Physician's Telephone orders revealed an order on 12/23/13 "Cefepime 2 gms IV Q 12 h x 6 week. Stop on 2/4/14. Cipro 500 mg 1 tab PO (mouth) BID (twice a day) for 6 weeks. Stop on 2/4/14." There were no orders related to the resident's tizanidine order. Review of Resident #16's Medication Administration Records for December 2013 and January 2014 revealed the resident continued to receive Cipro and tizanidine 12/23/13 - 1/7/14. In an interview with the surveyor on 1/7/14 at approximately 10:10 AM, the Director of Nurses (DON) stated that they called the hospital to find out why Resident #16 had a PICC line and were told that the resident should be on IV (intravenous) antibiotics. The hospital faxed over the Discharge Summary Addendum that included information related to the IV antibiotics on 12/23/13. During interview at 10:30 AM the DON confirmed that the tizanidine should have been di… | 2015-08-01 |
| 9122 | 9122 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 333 | E | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the First Revisit survey, based on record review and interview, the facility failed to ensure that residents are free of any significant medication errors. Resident #4 had a medication ordered 12/12/13 that was never started. Resident #17 had a medication ordered 1/6/14 that was profiled on the medication administration record to start 1/16/14. Two of 9 residents reviewed for medication errors. The findings included: Review of Resident #17's medical record on 1/7/14 revealed Physician Telephone orders dated 1/6/14 "[MEDICATION NAME] 875 BID (twice daily) #20" for "raised [MEDICAL CONDITION] left thigh"and "[MEDICATION NAME] powder to area between thighs bilaterally use powder QID (four times daily) x 10 d(ays)" for yeast infection. Both orders were signed by the nurse on 1/6/14 at 8:00 PM. Review of the Medication Administration Record (MAR) for January 2014 revealed the order for [MEDICATION NAME] powder was profiled with a start date of 1/6/14 and was signed as administered on 1/6/14 at 9:00 PM and on 1/7/14 at 9:00 AM. The order on the Medication Administration Record was for "[MEDICATION NAME] Powder to area between thighs bilaterally apply topically BID (twice daily) x 10 days." There was no clarification order or Nurses Note related to the discrepancy in administration times. Further review of the MAR for January 2014 revealed the order for "[MEDICATION NAME] 875 MG PO BID x 10 days" with a start date of 1/16/14. There was no clarification order or Nurses Note related to the discrepancy in start date. The medication had not been administered as of 1/7/14 at 2:55 PM. During interview with the surveyor on 1/7/14 at approximately 2:55 PM, the Director of Nurses (DON) stated that the yellow copy of the Physician's Telephone Orders are reviewed in morning meeting and checked to make sure they are profiled correctly. The DON stated that the nurse at night on 1/6/14 should have done a 24 hour chart check and noted the order for … | 2015-08-01 |
| 9123 | 9123 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 281 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the first revisit survey based on record reviews and interviews, the facility failed to assess and/or document acute conditions for 3 of 3 residents with acute changes. Res. #18, #4, and #17 experienced acute changes in condition without assessments or documentation. Resident #18 was admitted with an order for [REDACTED].#4 and #17 had a change in condition requiring medical treatment but there was no documentation of assessment related to the treatments as administered. In addition, Resident #17 had physician orders related to monitoring intake and output which were not clarified by staff to allow for standard facility policy. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the Hospital Transfer Record dated 1/2/14 stated the resident had a history of [REDACTED]. The resident had low hemoglobin and received packed red blood cells while in the hospital. Review of the hospital Medication Administration Record [REDACTED]. The hospital discharge medications included an order for [REDACTED].n. (as needed) for [MEDICAL CONDITION]. Review of the resident's Interim Care Plan dated 1/2/2014 revealed a problem, "at risk for bleeding R/T (related to) use of anticoagulant. [MEDICATION NAME] ([MEDICATION NAME]) had been checked and marked out. [MEDICATION NAME] was checked. Interventions included to monitor for bruising and bleeding" and "notify the MD (Medical Doctor)". Review of Resident #18's Physician's telephone orders dated 1/6/2014 stated, "Check CBC (Complete Blood Count) UA (urinalysis) CMP (Comprehensive Metabolic Panel) ". Under the section titled "Indication Dx (diagnosis)" gave the reason for the lab tests as "Tarry stool, dk (dark) urine". Review of the Departmental Notes revealed Nursing Notes dated 1/2/14 and 1/6/14 with no documentation related to "Tarry stool, dk (dark) urine". There was no documentation of an assessment of the resident's condition or a nurse's note that stat… | 2015-08-01 |
| 9527 | 9527 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-12-20 | 157 | D | 1 | 0 | PRCO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on observations, record review and interview, the facility failed to consult with the resident's physician regarding a significant change for Residents #1 and #2. Resident #1's oxygen saturation levels were in the 80's, he was not using [MEDICAL CONDITION] as ordered, he was attempting to get out of bed and physical therapy increased his oxygen level to 10 liters per minute and Resident #2 had multiple episodes of "chest pain", new onset of intermittent confusion and unclear speech. The physician was not notified in a timely manner regarding the changes that occurred with these two residents. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] at 1:30 AM. Review of the Nurses Notes revealed on [DATE] at 8:00 AM, "Pt (patient) experiencing SOB (shortness of breath). Respirations 24 and shallow. Crackles auscultated in upper lobes bilaterally. O2 sat 88% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Suctioned x 2. Pulled up in bed. Lung sounds clear. O2 sats (increased) to 92%. Respirations 22. Breathing still labored. HOB (head of bed) up 45 degrees. Bed in lowest position, side rails up x 2. Call light in reach." At 1:00 PM, "Pt O2 sat 80% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Pt very far down in bed. Respirations 22 and labored. Small amount of thick yellow mucous noted in trach. Suctioned x 1. Crackles heard in upper lobes bilaterally when auscultated. Suctioned x 2. Lung sounds clear. Pulled up in bed. Breathing tx (treatment) c (with) CPT machine in place. O2 sats remain in lower 80's. RT notified. O2 increased to 10 LPM, 40 % FiO2. O2 sats increased to 94%. HOB up 45. Bed in lowest position, side rails up x2, call light in reach." At 5:25 PM, "Pt found lying at foot of bed. [MEDICAL CONDITION] removed. Pt immediately placed back at head of bed. [MEDICAL CONDITION] placed back on. O2 sats 88% … | 2015-04-01 |
| 9528 | 9528 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-12-20 | 281 | D | 1 | 0 | PRCO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review, observation, interviews, review of the professional resource of Lippincott Manual of Nursing Practice Ninth Edition the facility failed to provide services that met professional standards of quality for one of ten residents (Resident #1). The facility failed to adequately assess Resident #1's oxygen saturation levels, failed to provide interventions when he removed [MEDICAL CONDITION] and/or attempted to get out of bed and failed to document all physician ordered treatments when administered per CPT vest (chest percussion therapy). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] at 1:30 AM. Review of the Nurses Notes revealed on [DATE] at 8:00 AM, "Pt (patient) experiencing SOB (shortness of breath). Respirations 24 and shallow. Crackles auscultated in upper lobes bilaterally. O2 sat 88% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Suctioned x 2. Pulled up in bed. Lung sounds clear. O2 sats (increased) to 92%. Respirations 22. Breathing still labored. HOB (head of bed) up 45 degrees. Bed in lowest position, side rails up x 2. Call light in reach." At 1:00 PM, "Pt O2 sat 80% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Pt very far down in bed. Respirations 22 and labored. Small amount of thick yellow mucous noted in trach. Suctioned x 1. Crackles heard in upper lobes bilaterally when auscultated. Suctioned x 2. Lung sounds clear. Pulled up in bed. Breathing tx (treatment) c (with) CPT machine in place. O2 sats remain in lower 80's. RT notified. O2 increased to 10 LPM, 40 % FiO2. O2 sats increased to 94%. HOB up 45. Bed in lowest position, side rails up x 2, call light in reach." At 5:25 PM, "Pt found lying at foot of bed. [MEDICAL CONDITION] removed. Pt immediately placed back at head of bed. [MEDICAL CONDITION] placed back on. O2 sats 88% on 10 LPM, 40 % FiO2. Encouraged to take deep breaths… | 2015-04-01 |
| 9529 | 9529 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-12-20 | 309 | D | 1 | 0 | PRCO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review and interview the facility failed to ensure one of ten residents received the necessary care and services to attain or maintain the highest practicable physical well being. Through a lack of coordination between the facility and the [MEDICAL TREATMENT] center the nursing facility failed to implement a fluid restriction ordered for Resident #9 by the [MEDICAL TREATMENT] clinic and failed to monitor the resident's intake as required. The findings included: The facility initially admitted Resident #9 on 9/16/2011 and readmitted her on 10/24/2011 following hospitalization for a cardiopulmonary arrest while at [MEDICAL TREATMENT] for treatment of [REDACTED]. Record review on 12/20/2011 at 11:05 AM revealed that on 10/28/2011, the resident was hospitalized again "with shortness of breath and chest pain and was found to be volume overloaded and in [MEDICAL CONDITION]... She was dialyzed aggressively for treatment of [REDACTED]. She was found to have bilateral pleural effusions and underwent bilateral thoracentesis..." Resident #9 was readmitted to the facility on [DATE]. Additional [DIAGNOSES REDACTED]. Based on record review and interviews the facility failed to implement a fluid restriction ordered by the [MEDICAL TREATMENT] clinic and failed to monitor the resident's intake as required. Record review on 12/19/2011 at approximately 6:30 PM revealed that the resident was on [MEDICAL TREATMENT] three times weekly. Review of the [MEDICAL TREATMENT] Communication Sheets revealed that on 11/9/2011, "Pt (Patient) came in c (with) a 4.7 kg gain. This is to(o) much." On 11/14/2011, the [MEDICAL TREATMENT] Communication Sheet noted the resident on a "1200 ml (milliliter) fluid restriction" and that the resident "Had wt (weight) gain of 4.1 (kg) from previous post weight. Please make sure Pt only has 1200 ml a day of fluid. This includes ice cream and gelatins." Review of the clinical r… | 2015-04-01 |
| 9530 | 9530 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-12-20 | 514 | D | 1 | 0 | PRCO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review and interview the facility failed to ensure one of one resident clinical records were accurate and complete. Resident #1's Physician order [REDACTED]. Nursing Notes were not timed and the November 2011 Medication Administration Record [REDACTED] The findings included: The facility admitted Resident #1 on 11/4/2011 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Orders revealed five out of nine telephone orders were without dates or times. Review of the Admission Nursing Notes revealed no time was recorded when the resident entered the facility or what time the assessments were completed. Review of the Nursing Admission Evaluation revealed "Section A: Arrival Time" was left blank. The resident's history and clinical concerns were not recorded on the Evaluation. Review of the Medication Administration Record [REDACTED]. During an interview on 12/5/2011 at 2:30 PM, the Respiratory Therapist stated that he provided the CPT Vest to the resident on 11/4/2011 and that it wasn't documented. During an interview on 12/5/2011 at 3 PM, the Director of Nurses confirmed the physician's orders [REDACTED]. She also confirmed that the Nurses Notes and Nursing Evaluation did not have times recorded. She stated that the nursing staff should date and time orders and their notes. | 2015-04-01 |
| 9531 | 9531 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2011-12-20 | 518 | F | 1 | 0 | PRCO11 | On the days of the Complaint and Extended Survey, the facility failed to ensure the staff was trained on emergency fire procedures as required. There was no documented training for either the 3-11 or 11-7 shifts during the last quarter. The findings included: Review of documented fire drills on 12/20/2011 at 4:30 PM revealed that drills were not conducted quarterly on each shift as required to determine the efficiency, knowledge, and response of facility personnel. The Fire Drill Schedule provided by the facility indicated that drills were scheduled for each shift on a rotating basis. However, review of the drills actually conducted revealed that the 11-7 shift had not had a drill since May 2011 and the 3-11 shift had not had a drill since July 2011. Fire drills were conducted on the 7-3 shift during the months of August, September, and October 2011. When requested, the Maintenance Supervisor was unable to produce any additional information. During an interview on 12/20/2011 at 4:55 PM, in the presence of two maintenance personnel, the Administrator reviewed and confirmed this information. It was pointed out that the Fire Drill Book had dividers for each month that specified the shift on which the drill should have been conducted. The Administrator verified that the fire drills had not been conducted as required. | 2015-04-01 |
| 10296 | 10296 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2010-09-14 | 328 | E | DZ1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that residents received treatments as ordered by the physician for 1 of 2 residents reviewed who had nebulizer treatments ordered (#2). Resident #2 did not receive the nebulizer treatments ordered on [DATE] until 8/17/10. The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes revealed a note on 8/12/10 at 10:15 PM stating: "Resident noted to have cough (with) congestion. Notified MD." The physician saw the resident on 8/13/10 and wrote in his progress note that the resident was "... quite short of breath and feeling terrible. ..." A treatment plan was documented in the progress note including "Start [MEDICATION NAME] solution 2.5 mg/3mL (2.5 milligrams per 3 milliliters), (0.083%), 3 mL, Q 4 hrs. (every four hours) while awake x (times) 5 days, then prn (as needed for) wheeze. ..." Antibiotics, nasal oxygen, a chest x-ray, and a speech therapy consult were also ordered for suspected aspiration pneumonia. The 8/13/10 Daily Skilled Nurses Note at 6 PM documented that the resident was coughing but had no complaint of pain. He was resting in bed. The nurse's note documented that the physician wrote new orders for oxygen, nebulizer treatments, and a chest x-ray. The chest x-ray was done and no infiltrates were noted. Speech Therapy evaluated the resident and changed his diet. A swallow study was scheduled for 8/16/10. The nurse's note ended with "... No distress when eating supper. Will monitor." Review of the physician's orders [REDACTED]. "Chest x-ray Re: poss (possible) aspiration pneumonia "[MEDICATION NAME] 100 mg PO (by mouth) BID (two times a day) x 10 days, 1st dose STAT "[MEDICATION NAME] 500 mg PO BID x 10 days, 1st dose STAT "[MEDICATION NAME] 2.5mg/3mL via neb q 4 (hours) while awake x 1 week, then PRN "Oxygen 2 L/min (liters per minute) via nasal cannula" This order was signed by the physician … | 2014-01-01 | ||
| 8296 | 8296 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 157 | K | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record review, interviews, and review of the facility's policy entitled Condition Change, the facility failed to notify the attending physician in a timely manner of changes in residents' physical conditions, which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION]. Three of these four developed symptoms after admission to the facility. This failure to notify the physician in a timely manner resulted in significant delays in treatment and potential for transmission of infection. (Resident # 1, 4, 8 and 12) The findings included: The facility admitted Resident #1 on 8/26/11 following hospitalization for Altered Mental Status. She was discharged with [DIAGNOSES REDACTED]. The hospital discharge summary noted that she had been treated with [MEDICATION NAME], which had been changed to [MEDICATION NAME] to continue at the nursing facility until 9-2-11. Review of Physician Telephone Orders with the Assistant Director of Nurses (ADON) on 5-1-12 at 10:20 AM revealed that on 8-27-11, the physician ordered intravenous fluids for dehydration. On 8-29-11, the resident was started on [MEDICATION NAME] IM (intramuscular) for 3 days for signs and symptoms of a UTI. Review of the Daily Skilled Nurse's Notes with the ADON revealed that on 9/8/11, the resident had a watery, foul smelling stool. The physician was notified and ordered a stool specimen to check for [MEDICAL CONDITION]. On 9/9/11, the facility was notified of a positive result and the physician ordered treatment with [MEDICATION NAME] for 10 days and isolation precautions. [MEDICATION NAME] was completed on 9-19-11. Review of the computerized Activities of Daily Living (ADL) Records on 5-1-12 at 11 AM with Certified Nursing Assistant (C… | 2016-06-01 |
| 8297 | 8297 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 164 | D | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview and review of the facility's policy entitled Wound Care dated April 2009, the facility failed to assure that 1 of 3 sampled residents observed for medical treatments were provided with privacy during the treatment procedure. The Assistant Director of Nursing (ADON) did not pull the privacy curtain all around the Resident 15's bed while performing a treatment to the resident's sacrum. The findings included: The facility admitted Resident #15 on 8/11/11 with [DIAGNOSES REDACTED]. The Resident acquired a Sacral Decubitus. During preparation for wound care observation on 4/30/12 at 4:37pm, the ADON pulled the privacy curtain between the beds, but not around the foot of the bed failing to ensure total privacy. The Resident was in a semi-private room and her bed was located next to the window. While providing wound care, the Resident's sacral area was exposed toward the room door. The roommate was present in the room, sitting in a wheelchair on the other side of the curtain and was at times observed tugging on the curtain and becoming agitated. During an interview on 5/2/12 at 10:30am with the ADON regarding the routine procedure for providing privacy during a wound treatment, she stated I will have to check on that. On 5/2/12 at 10:50am, the ADON offered more information on providing privacy and stated, It's our practice to close the door and pull the curtain half way. Anyone entering the room would knock on the door and have been asked to wait one minute due to doing care. The facility's policy entitled Wound Care provided by the facility on 5/2/12 at 12:20pm did not address provision of privacy. However, the policy stated following the treatment If the resident desires, return the door and curtains to the open position . | 2016-06-01 |
| 8298 | 8298 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 315 | D | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the professional resource of Perry & Potter Clinical Nursing Skills & Techniques 7th Edition, page 892, the facility failed to ensure appropriate treatment and services were rendered for 1 of 1 resident observed for suprapubic catheter care. (Resident #24) Registered Nurse # 1 failed to secure the catheter to prevent pulling while cleaning the catheter. The findings included: The facility admitted Resident # 24 on 4/1/12 with the [DIAGNOSES REDACTED]. During the observation of the suprapubic catheter care on 5/1/12 at 1:50 PM Registered Nurse # 1 failed to secure the tube at the stoma site while cleaning the tube. During a interview with the nurse at 2:00 PM on 5/1/12, she confirmed that she should have held the tube at the stoma to clean the tube. Review of the professional resource of Perry & Potter Clinical Nursing Skills & Techniques 7th Edition, page 892, states Unsecured catheters lead to enlargement of the [MEDICATION NAME] tract, leakage and the need for larger diameter catheters. | 2016-06-01 |
| 8299 | 8299 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 425 | D | 0 | 1 | YK4D11 | On the days of the survey, based on observation, interview, and review of the manufacturers recommendations for storage, the facility failed to ensure that two Novolog Mix 70/30 flex pen (insulin) medications were dated when opened. (1 of 4 medication carts reviewed for appropriate medication storage.) The findings included: Observations made on 4/30/12 of the Unit 100 medication cart A revealed two Novolog Mix 70/30 flex pens that had a label, which read discard in 28 days. Another sticker had a hand written date with an expiration date of 5/16/12. There was no open date noted on the pens. Registered Nurse # 2 stated I think they expire in 28 days. On 5/1/12 the Director of Nursing stated during an interview that insulin pens are good for 14 days after opening. The manufacturer patient information related to the storage of Novolog flex pens states: Expiration: Each Novolog pen should be used within 28 days once out of the refrigerator. Once in use, insulin delivery systems should not be refrigerated. | 2016-06-01 |
| 8300 | 8300 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 441 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observations, interviews, and review of facility infection control policies and procedures and tracking documents, the facility failed to implement treatment and contact precautions in a timely manner, and/or failed to ensure contact precautions were maintained, and/or failed to ensure accurate monitoring and tracking of infections for 7 of 9 residents reviewed who had positive test results for Clostridium Difficile (C-Diff), (Residents #1, #4, #5, #6, #8, #10, and #12). The physician was not notified of the onset of gastrointestinal signs and symptoms of Clostridium Difficile (C-Diff) in a timely manner for four of nine sampled residents reviewed with[DIAGNOSES REDACTED] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for[DIAGNOSES REDACTED] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of[DIAGNOSES REDACTED] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation … | 2016-06-01 |
| 8301 | 8301 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 490 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Survey, based on observation, record review and interviews, facility administration failed to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. The findings included: On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that The Administrator will be responsible for oversight of the Infection Control Program. During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional inservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. During an intervie… | 2016-06-01 |
| 8302 | 8302 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 492 | D | 0 | 1 | YK4D11 | On the days of the survey, based on record review and interview, the facility failed to provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility related to completing appropriate background checks prior to hire. (1 of 5 employee files reviewed.) The findings included: Review of one personnel record revealed that no South Carolina background check had been completed prior to the hire for a Registered Nurse (RN). She was hired on 1-25-12. Further review of her personnel file revealed an out of state (Tennessee) criminal background check was completed. However, review of her employment application revealed that she had been in the state of South Carolina since at least March of 2008. An interview with the Financial Officer on 5-1-2012 at 12:40 PM confirmed this surveyors findings and verified that no South Carolina Law Enforcement Division background check had been completed prior to her hire date. | 2016-06-01 |
| 8303 | 8303 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 501 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observation, and interviews, the Medical Director failed to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. The facility failed to involve the Medical Director in the ongoing evaluation of monitoring infections within the facility and implementation of infection control policies and procedures. The findings included: Based on record reviews and interviews, the physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of… | 2016-06-01 |
| 8304 | 8304 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 520 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on review of quality improvement documents, record reviews, and interviews, the facility failed to identify ongoing quality deficiencies related to monitoring and implementing infection control policies and procedures. The QAA Committee failed to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The findings included: During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional disservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or ma… | 2016-06-01 |
| 8539 | 8539 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2013-03-29 | 247 | D | 1 | 0 | Y7B111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification and complaint surveys, based on record review and interview, the facility failed to notify the resident/family in advance of room changes, affording them the opportunity to accept/refuse the new accommodation, for one of three residents reviewed for room changes. Staff failed to give prior notification to Resident #94's family to consider the potential roommate's condition as s/he was actively dying. The findings included: Review of Nurses Notes on 3-27-13 revealed an entry on 2-22-13 at 0716: Resident currently displaced to room [ROOM NUMBER]A . There was no documentation in the Nurse's Notes as to when Resident #94 was relocated or for what reason. All Nurses Notes from 2-8-13 through date of discharge noted the resident in room [ROOM NUMBER]B. Social Service Notes were reviewed on 3-27-13 at 4:53 PM. There was no mention of room changes. No Physician's Orders were noted for room changes. However, there was a 2-21-13 Telephone Order to DC (Discontinue) isolation precautions. On 3-28-13 at 10:03 AM, the Administrator reviewed and provided copies of Room Changes communication forms. One untimed form dated 2-21-13 noted the reason for relocation as no longer on precautions/deep clean. A second untimed form dated 2-25-13 noted a return to the previous room on 2-25-13. The reason for relocation was noted as room deep cleaned and ready for return. Both room change forms noted family notification on the date the room changes were made. There was no evidence that the resident was notified of the proposed room changes in advance, providing her/him an opportunity to see the new location, meet the new roommate, and to ask questions about the move. Review of Resident #94's 2-12-13 Admission and 2-19-13 14-day Minimum Data Set (MDS) Assessments on 3-27-13 at 11:36 AM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. Section B of t… | 2016-03-01 |
| 8540 | 8540 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2013-03-29 | 309 | E | 1 | 0 | Y7B111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification and complaint survey, based on record reviews and interviews, the facility failed to ensure that residents received routine pain medication as ordered as part of a pain management program for 1 of 4 sampled residents reviewed for pain. Resident #94, a resident with chronic pain, did not receive [MEDICATION NAME] as ordered. The facility also failed to provide skin treatments as ordered for one of four residents reviewed for impaired skin integrity. Resident #94 was documented as having impaired skin integrity from the time of admission, but topical medications were not applied as ordered. The findings included: Review of the 2-12-13 and 2-19-13 Minimum Data Set (MDS) Assessments on 3-27-13 at 11:36 AM revealed that Resident # 94 had a BIMS (Brief Interview for Mental Status) score of 13, indicating s/he was cognitively intact. The resident required extensive to total care with all activities of daily living except eating. Range of motion was impaired in upper and lower extremities on one side. The resident was on scheduled pain medication and as needed medication was added on the second MDS. Occasional pain was noted at a rating of one to 3. Resident #94 was noted at risk for pressure ulcers and receiving skin ointment. [DIAGNOSES REDACTED]. S/he was admitted on transmission-based precautions and was receiving therapy. Review of the 2-26-13 Care Plan on 3-27-13 at 1 PM revealed that the potential for skin breakdown related to incontinence and impaired mobility for Resident #94 was addressed, in part, by approaches including checking the resident every two hours, applying 'barrier ointment, and treatments as ordered. The Interim Care Plan completed on admission also addressed skin integrity concerns. Record review on 3-27-13 at 12:34 PM revealed an admission 2-6-13 skin assessment noting a reddened area on the coccyx/sacral area. No other skin assessments were noted in the medical record. The Administrator an… | 2016-03-01 |
| 8541 | 8541 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2013-03-29 | 425 | D | 1 | 0 | Y7B111 | On the days of the recertification and complaint surveys, based on record review and interviews, the facility failed to document disposition of medication for one of two residents reviewed for discharge. There was no accurate listing of medications and their disposition at the time of discharge for Resident #94. The findings included: Record review on 3-27-13 at 12:34 PM revealed that Resident #94 was discharged to an assisted living facility on 3-20-13. Review of the Discharge Instructions for Care signed by the family revealed that the staff failed to note disposition of the medications. The medications list failed to include instructions for currently ordered medications for routine administration at the time of discharge-Effexor 37.5mg (milligrams) daily; Indocin 50mg three times daily , Calcium 1000mg twice daily; Ferrous Sulfate 325mg twice daily; and Hydrocodone/Acetaminophen 5-325 mg twice daily. No reference was made to Vicodin 5/500 mg ordered on an as needed basis. Review of the 3-13 Medication Administration Record [REDACTED]. Review of Nurses Notes on 3-28-13 at 8.28 am revealed an entry on 3-20-13 7P-7A shift that Resident #94 was discharged to another facility. No disposition of current medication was noted. No Physician's Order could be located for this resident to be discharged with medications. During an interview at 10:25 AM on 3-28-13, the Director of Nurses (DON) and Assistant Director of Nurses reviewed the record and the Discharge Instructions for Care and verified there were no records of individual prescriptions sent or a count of the number of medications sent from the facility. The DON stated that staff typically sent narcotics home with residents upon discharge, along with prescriptions for the rest of the medications. It was stated that all remaining medications were sent with Resident #94 upon discharge. However, there was no accounting for disposition of the medications. They confirmed that Hydrocodone and Effexor were not noted on the medication list. Although the Nurse Practitione… | 2016-03-01 |
| 8841 | 8841 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 157 | G | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the complaint inspection, based on record review and interviews, the physician was not notified of a skin tear to Resident #3's left arm or Resident #1's change in condition. The findings included: Cross refers to F-323 as it relates to the failure of the facility to notify the physician of a skin tear to Resident #3's left arm on 09/14/2012. Cross refers to F-329 as it relates to the family of Resident #1 calling Emergency Medical Services (EMS) on 11/03/2012, EMS found 4 [MEDICATION NAME] Patches on the resident. The resident was found with decreased respirations and a blood glucose of 36. [MEDICATION NAME] and [MEDICATION NAME] were administered by EMS and the resident's vital signs improved and s/he became alert and oriented before arrival at the emergency room . Review of the closed medical record revealed [MEDICATION NAME] Patch(s) 25 micrograms was applied to Resident #1's chest upper left and upper right on 10/27/2012 and 10/30/2012 with no documentation that the [MEDICATION NAME] Patches were removed. On 11/02/2012 a [MEDICATION NAME] Patch was applied to Resident #1's chest upper left. The facility admitted Resident #3 from home with hospice care, for short term respite. In an interview with Certified Nurse Aide #1 s/he stated that the resident was injured during incontinent care sometime before midnight on 09/14/2012. Review of the resident's closed medical record showed no assessment or description of the injury and the physician was not notified of the injury from 09/14/2012 until the resident was discharged on [DATE]. Review of the facility investigation included a Resident Incident Report that indicated the incident date was 9-15-12 at 0335. The Narrative of incident and description of injuries stated, Call to room . observed skin tear to bilateral forearms. No other injury noted tx (treatment) in place. Hospice and family notified . Record review on 11/18/2012 revealed Nurse's Note from 09/14/2012 - 09/17/2012 the 9… | 2015-12-01 |
| 8842 | 8842 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 226 | E | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, information provided by the facility and interviews, the facility failed to follow their Policies Procedures related to abuse and neglect for 3 of 6 residents reviewed. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1's family on 11/03/2012 called EMS (emergency medical services) to the facility, EMS found 4 [MEDICATION NAME] Patches on the resident. The resident was found with decreased respirations and a blood glucose of 36. [MEDICATION NAME] and [MEDICATION NAME] were administered by EMS and the resident's vital signs improved and s/he became alert and oriented before arrival at the emergency room . Review of the closed medical record revealed [MEDICATION NAME] Patch(s) 25 micrograms was applied to Resident #1's chest upper left and upper right on 10/27/2012 and 10/30/2012 with no documentation that the [MEDICATION NAME] Patches were removed. On 11/02/2012 a [MEDICATION NAME] Patch was applied to Resident #1's chest upper left. Review of the facility investigation indicated the Ombudsman contacted the facility via telephone regarding an allegation made by the hospital that Resident #1 was brought to the emergency room with multiple [MEDICATION NAME]es on his/her body. The investigation failed to include witness statements from all staff caring for the resident at the time of the incident; failed to include a statement from the nurse who applied the [MEDICATION NAME]es or the nurses who conducted the body audit on admission. Resident #2 sampled as a result of a complaint related to an injury of unknown origin that was not addressed. The complainant alleged that the staff treated the resident's pain after s/he brought it to their attention but was unable to tell her/him what happened to the resident's knee. Record review on 11/18/2012 revealed Resident # 2 was admitted to the facility per the hospital Discharge Summary dated… | 2015-12-01 |
| 8843 | 8843 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 281 | D | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to assess and care plan sufficiently to meet the needs of a newly admitted resident. The Interim Plan of Care was not complete for 2 of 2 residents reviewed for interim plan of care (Resident #2 and #3). The findings included: The facility admitted Resident #3 with a [DIAGNOSES REDACTED]. Record review on 11/18/2012 revealed a Nurse's Note dated 9/14/2012 at 0335 that stated, Pt (patient) received skin tear to bilateral hands/forearm hospice nurse notified and husband notified. In an interview with the surveyor on 11/27/2012 at 12:25 PM Certified Nurse Aide (CNA) #1 stated the incident happened sometime before midnight on 9/14/2012; that s/he had seen the resident at around 7:00 PM when s/he first came to work. At 7:00 PM s/he was given report by the CNA that was leaving, that the resident was dry and the previous CNA told her/him that Resident #3 was a total assist. That was all she said. CNA #1 stated that the next time s/he went back to check on the resident was when s/he and CNA #2 changed her, sometime before midnight. CNA #1 stated that when they rolled the resident toward her/him the resident was panicky, reached up and grabbed the name tag holder cutting her/his arm on the name tag. We had to hold her/his arm while we changed her. Review of Resident #3's Interim Plan of Care dated 09/14/2012 identified a risk for alteration in skin integrity due to incontinence. Interventions included meds as ordered, assist to turn and reposition as needed, incontinence care as needed, monitor skin integrity weekly and prn, and treatments as ordered. The care plan indicated, Actual skin alteration Site: Bil (bilateral) L/E (lower extremity) skin tears dated 9-14-12. In an interview with the surveyor on 11/27/2012 at 9:15 AM Resident #3's Responsible Party (RP) stated that s/he e-mailed detailed information regarding the resident's care prior to her/his … | 2015-12-01 |
| 8844 | 8844 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 323 | G | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to implement interventions to reduce the risk of skin tears and injury for Resident #3, and failed to document any ongoing assessment of the injured arm or notify the physician post injury for additional medical intervention. Resident #3 was treated for [REDACTED]. Resident #3 was 1 of 2 residents reviewed for injury. The findings included: The facility admitted Resident #3 from home with hospice care, for short term respite. In an interview with Certified Nurse Aide #1 s/he stated that the resident was injured during incontinent care sometime before midnight on 09/14/2012. Review of the resident's closed medical record showed no assessment or description of the injury and the physician was not notified of the injury from 09/14/2012 until the resident was discharged on [DATE]. The only documentation following the injury was a Nurse's Note dated 09/16/2012 at 9:30 PM. The facility admitted Resident #3 with a [DIAGNOSES REDACTED]. Record review on 11/18/2012 revealed Nurse's Note from 09/14/2012 - 09/17/2012 the 9/14/2012 note at 0335 stated, Pt (patient) received skin tear to bilateral hands/forearm hospice nurse notified and husband notified. There was no other documentation regarding the skin tear to Resident #3 arm until 09/16/2012 at 2130 (9:30 PM) .Bilateral tegaderm intact on both arms . On 09/17/2012 at 1230 the Nurse's Note stated, Pt. (patient) D/C'd (discharged ) home per husband/hospice request . All meds given to husband . 1:00 PM Pt's husband notified Administrator that he chose to have the ambulance go ahead and take her/him to the hospital for evaluation of skin tears to arms prior to going home. Husband encouraged to keep us posted on her status. Review of Resident #3's hospital discharge summary dated 09/21/2012 indicated, .Hospital course: . 7. Cellulitis of the arm. The patient was found to have old pieces of paper wrapped arou… | 2015-12-01 |
| 8845 | 8845 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 329 | E | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the complaint inspection, based on record review and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs. Resident #1 received pain medication without adequate monitoring by the facility staff. The findings included: When called to the facility by Resident #1's family on [DATE], EMS (emergency medical services) found 4 [MEDICATION NAME] Patches on the resident. The resident was found with decreased respirations and a blood glucose of 36. [MEDICATION NAME] and [MEDICATION NAME] were administered by EMS and the resident's vital signs improved and s/he became alert and oriented before arrival at the emergency room . Review of the closed medical record revealed [MEDICATION NAME] Patch(s) 25 micrograms was applied to Resident #1's chest upper left and upper right on [DATE] and [DATE] with no documentation that the [MEDICATION NAME] Patches were removed. On [DATE] a [MEDICATION NAME] Patch was applied to Resident #1's chest upper left. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the closed medical record revealed a physician's orders [REDACTED]. Review of the EMS Incident Report dated [DATE] stated, .Upon arrival found . patient lying in bed . Nurse staff stated that patient eyes rolled back into his head and s/he has not been able to talk today. Patient was assessed to find (4) [MEDICATION NAME] 50 MCG (microgram) patches still located on patient. All four were removed and stuck to patient chart. Patient's BGL (blood glucose level) was checked (36). Patient was given an IV (intravenous) . Patient was given one amp of DO ([MEDICATION NAME]) 50 (25 G) (grams) and loaded for transport, patients respiratory rate was between ,[DATE] BPM (breaths per minute). Patient placed on high flow O2 at 10 LPM (liters per minute), and given 2 MG (milligrams) of [MEDICATION NAME]. Resp (respiratory) rate came up to ,[DATE] BPM. EN route to ER (emergency room ), vitals a… | 2015-12-01 |
| 8846 | 8846 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 333 | D | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview the facility failed to ensure that Resident #2 was free of a significant medication error. Resident #2 failed to receive [MEDICATION NAME] 45 units at bedtime per physician's orders [REDACTED]. The findings included: Record review on 11/18/2012 revealed Resident # 2 was admitted per the hospital Discharge Summary dated 10/04/2012 with nonspecific chest pain, [MEDICAL CONDITIONS], diabetes and progressing dementia. Review of the admission Nurse's Notes indicated Resident #2 arrived at the facility on 10/04/2012 at 1300 (1:00 PM). Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Diabetic Monitoring Flow Sheet dated for 10/04/2012 show no fingerstick blood sugar results; the 10/05/2012 glucose test results at 6:05 AM was 422 after eating. Resident #2 went to [MEDICAL TREATMENT] after breakfast and did not return to the facility due to a hospital admission related to a painful knee. In an interview with the surveyor on 11/19/2012 at approximately 4:45 PM the facility consultant and the Administrator were unable to supply additional information regarding the failure to administer the [MEDICATION NAME]. | 2015-12-01 |
| 8847 | 8847 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-12-03 | 514 | E | 1 | 0 | 2MGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and record review, the facility failed to document the administration of a pain medication; giving a family member a pain medication to be used later at [MEDICAL TREATMENT] and failed to document that a family member notified emergency medical services of a change in a resident condition Resident #1 and #2. (2 of 7 resident records reviewed for clinical record accuracy and completeness. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the EMS Incident Report dated 11/03/2012 stated, .Upon arrival found . patient lying in bed (with family) . Nurse staff stated that patient eyes rolled back into his head and s/he has not been able to talk today . Review of the 11/03/2012 Daily Skilled Nurse's Note dated 0900 stated, Resident eating breakfast in bed. AM medications administered. Alert but confused. SR (side rails) x 2. Bed in lowest position. Wound Vac intact. Foley cath intact draining amber urine. Will continue to monitor. There was no other documentation that EMS was notified or the concerns that cause the family to call 911. Record review on 11/18/2012 revealed Resident # 2 was admitted per the hospital Discharge Summary dated 10/04/2012 with nonspecific chest pain, [MEDICAL CONDITIONS], diabetes and progressing dementia. Review of the Medication Administration Record [REDACTED]. The MAR failed to show that Resident #2 received the [MEDICATION NAME] during his/her stay at the facility. Review of the Controlled Drug Record indicated that Resident #2 on 10/05/2012 at 0500 received [MEDICATION NAME]-[MEDICATION NAME] 5/325 as ordered; another dose at 0600 was initialed and indicated to give at [MEDICAL TREATMENT]. There was no documentation in the Nurse's Notes related to the administration of the pain medication. The only nurse's note related to Resident #2 was written on 10/04/2012 at 1:00 PM, the day of admission. In an interview with the survey… | 2015-12-01 |
| 9655 | 9655 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2011-04-06 | 167 | C | 0 | 1 | CZEA11 | On the days of the survey based on observations and interviews, the facility failed to post the last Recertification Survey of February 2010 per Regulatory requirement. The findings included: On 4/4/2011 at 6:00 PM, the Survey Posting book was observed in the lobby of the front entrance. Review of the POS [REDACTED]. The Survey Book contained "Medicare.gov Nursing Home Compare - Previous Fire Inspection, and Medicare .gov Nursing Home Compare Previous Health Inspection". The Survey Posting book was observed on 4/5/11 at 10:00 AM and 2:00 PM, the actual survey results with the plan of correction was not available. During an interview with the DON (Director of Nurses) on 4/5/11 at 4:00 PM, she stated that she was unaware that the actual survey was to be posted. On 4/6/11 at 11:00 AM, the Administrator stated that the Recertification Survey had been placed in the book. During the resident group interview on 4/5/2011 at 2:00 PM, the residents stated they were unaware of the posting of the survey results. | 2015-02-01 |
| 9656 | 9656 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2011-04-06 | 496 | D | 0 | 1 | CZEA11 | On the days of the survey, based on record review and interview, the facility failed to assure that 1 of 3 certified nursing assistants had a current South Carolina (SC) Nurse Aide Certification and that the South Carolina Registry was checked prior to hire. One personnel file reviewed revealed a CNA had a certification from North Carolina but did not have a current SC certification. The findings included: On the days of the survey, three Certified Nursing Assistant files were reviewed. One file revealed the CNA was certified in North Carolina and only the registry from North Carolina had been checked prior to employment. There was no evidence provided that the CNA held a current South Carolina (SC) certification or that the South Carolina registry had been checked prior to hire. According the the South Carolina Nurse Aide Program, a CNA "cannot work in SC until the process is completed." | 2015-02-01 |
| 9657 | 9657 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2011-04-06 | 309 | D | 0 | 1 | CZEA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews, the facility failed to maintain intake and output for 1 of 1 resident, Resident #5, admitted with fluid restriction. The findings included: The facility admitted resident #5 on 3/30/2011 with [DIAGNOSES REDACTED]. The Admission Cumulative orders dated 3/30/11 contained an order for [REDACTED]. A Medical Nutritional Therapy Assessment was completed on 3/31/11, that stated resident was on 1,000 cc fluid restriction. Review of the Intake and Output record on 3/30/2011 had documented on the 11-7 shift 420 cc of intake. On 4/1/11 the intake was documented to be 300 cc on the 7-3 shift. There was no documented intake on the 3-11 or the 11-7 shift. On 4/2/11, the 7-3 shift had documented 420 cc intake, there was nothing documented for the 3-11 or 11-7 shift. There was no documentation for 4/3/11 of any intake. A Fluid Restriction Worksheet was available that defined the amounts of fluids by shift and what was to be provided by dietary and the amounts to be provided by Nursing. The amounts of fluids that were scheduled by the Fluid Restriction Worksheet did not match the intake record of the resident. On 4/6/11 at 10:30 AM, RN (Registered Nurse) #2 reviewed the Intake and Output record and fluid restriction sheet. She agreed the records did not match and the fluid was not distributed as outlined. The resident's actual fluid intake could not be determined with the Intake record not being completed. | 2015-02-01 |
| 9658 | 9658 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2011-04-06 | 441 | D | 0 | 1 | CZEA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and policy review, the facility failed to provide infection control through proper handwashing for 1 of 1 residents observed for catheter care. Resident #3 had red drainage during catheter care. The CNA after cleaning the red drainage did not remove her gloves and touched various items in the room. The findings included: The facility admitted Resident #3 on 3/10/11 with [DIAGNOSES REDACTED]. During observation of catheter care on 4/5/11 at 10:15 AM, CNA #1 (Certified Nursing Assistant) wiped around the glans penis and obtained bright red staining on the 4 cloth wipes used. After completing the catheter care, with her contaminated gloves still on, she lowered the bed, elevated the head of the bed using the electric control, repositioned the brief and refastened the brief, obtained the graduate out of the bathroom, touched the privacy curtain and the privacy bag over the catheter bag, and pulled up the bedding . The facility policy provided by the facility on Catheter Care, states after completing the catheter care, "...remove gloves....Wash and dry hands thoroughly. Reposition bed cover. Make the resident comfortable....." | 2015-02-01 |
| 7906 | 7906 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2012-08-21 | 314 | D | 0 | 1 | 7JG911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview the facility failed to provide appropriate treatments for pressure sores for 2 of 2 residents observed for pressure sore treatments. Wound care was provided to Resident #2 and Resident #9 and the soiled brief left on the resident during the treatment was allowed to come in contact with the cleansed wound. The findings included: The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. On 8-21-12 at approximately 9:30 AM, this surveyor observed Licensed Practical Nurse (LPN) # 5 as she provided wound care for Resident # 2 with assistance from Certified Nursing Assistant (CNA) # 1. LPN #5 set up the supplies on the over the bed table, washed hands and gloved while CNA # 1 washed hands, gloved and assisted the resident with positioning. CNA # 1 unfastened Resident # 2's brief and left it under the resident, and LPN #5 placed a towel directly between the brief and the resident. This surveyor noted that there was a brown substance/stain on the brief which was directly under the bandage on the resident's sacral area. LPN #5 then removed gloves, washed hands and regloved while CNA #1 assisted the resident in maintaining the position to provide access to the wound. LPN #5 then removed the soiled dressing and gloves and sanitized hands and regloved. LPN #5 then sprayed normal saline over the wound area and patted the area dry with gauze. LPN #5 then used a small skin prep wipe and wiped several times over the same area of the wound. The LPN removed her gloves, sanitized her hands gloved and applied the Exuderm patch over the wound. LPN #5 then removed her gloves, washed her hands and regloved, removed the towel from under the resident allowing the soiled brief to come into contact with the clean dressing. LPN then bagged the soiled linen and trash, washed her hands and removed them from the room. CNA # 1 washed her hands and removed her gloves then left the room to get supplies to chang… | 2016-10-01 |
| 7907 | 7907 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2012-08-21 | 329 | D | 0 | 1 | 7JG911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the survey, based on record review and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 1 of 10 residents reviewed. Resident #2 received anti-[MEDICAL CONDITION] medication with no [DIAGNOSES REDACTED]. The findings include: The facility admitted Resident # 2 with the following Diagnoses: [REDACTED]. Review of the medical record on 08/20/2012 at approximately 3:00 PM revealed Physician Renewal Orders dated 08/01/2012 - 08/31/2012 which listed [MEDICATION NAME] 50mg Bid. Further review revealed no documentation to indicate a [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 08/21/2012 at 11:41 AM revealed the use of [MEDICATION NAME] had been addressed by the Pharmacist. The DON presented a written Pharmacy note dated 05/12/2012 which read MD (medical doctor) notes unclear why resident on [MEDICATION NAME] ([MEDICATION NAME]), but would not recommend d/c (discontinue). The DON stated after Pharmacy reviews a resident's medication regimen he/she prints out the results of pharmacist review and forwards them to the physician. Review revealed no documentation in the medical record to suggest the physician had been made aware of the pharmacist review. At this time the DON stated he/she would contact the pharmacist for clarification. Interview with the DON on 08/21/2012 at 1:45 PM revealed he/she had spoken with the Pharmacist and verified that the above concern had not been communicated to the Physician. The DON further stated that the Pharmacist had spoken with the Physician concerning the use of [MEDICATION NAME] for Resident #2 however the Physician had not discontinued the medication. | 2016-10-01 |
| 7908 | 7908 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2012-08-21 | 441 | E | 0 | 1 | 7JG911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, and interview the facility failed to provide a safe sanitary environment to help prevent the transmission of disease and infection for1 random observation of unwashed hands after sneezing, during medication pass; and 2 nurses who failed to clean the glucometer properly during Fingerstick Blood Sugars (FSBS). The findings included: During medication pass on 8-21-12 at approximately 8:10 AM, while LPN # 1 was pulling medications for a resident, she turned her head and sneezed, and covered her face with her right hand. Then she stated I have allergies [REDACTED]. During observation of FSBS (Fingerstick blood sugars) on 8-20-12 at 4:10 PM, LPN # 2 cleaned the glucometer with alcohol pads twice, before obtaining a FSBS from 2 separate residents. During another observation of FSBS at 4:40 PM the same day, Registered Nurse (RN) # 1 also cleaned the glucometer with alcohol pads. During an interview with the Director of Nursing on 8-21-12 at approximately 11:00 AM, he stated that all medicine carts should have Clorex wipes on them to be used by the nurses to clean the glucometers. Subsequent interviews with RN # 1 and LPN # 2 on 8-21-12 at approximately 12:45 PM, they both confirmed that there were no Clorex wipes on the medication carts. | 2016-10-01 |
| 7909 | 7909 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2012-08-21 | 514 | D | 0 | 1 | 7JG911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the survey, based on record review and interviews, the facility failed to meet this requirement as evidenced by inaccurate documentation for 1 of 17 records reviewed. Resident # 2 with inconsistent code status. The findings include: The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of medical record on [DATE] at approximately 3:10pm revealed the code status for Resident #2 was Full Code. Further review revealed that Resident #2 signed an Authorization of DNR (Do Not Resuscitate) dated [DATE] indicating The above resident, as deemed competent, has made the oral and/or written request to NOT have Cardiopulmonary Resuscitation (CPR) performed under any circumstances. Interview with Director of Nursing on [DATE] at approximately 6:00pm revealed Resident #2 completed and signed the DNR authorization upon admission but verified that the current Physician order [REDACTED]. | 2016-10-01 |
| 8252 | 8252 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2013-06-18 | 282 | E | 1 | 0 | B96711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review, observation and interview, the facility failed to ensure that each resident care plan was followed. The facility failed to follow care planned safety devices to prevent fall for 4 of 5 residents reviewed for falls (Resident #4, #5, #6 and #7). The findings included: Resident #4 was admitted to the facility on [DATE] for rehabilitation after having a hip repair. Review of the Discharge Summary from the hospital revealed Resident #4 was admitted to the hospital on [DATE] for a left [MEDICAL CONDITION] after s/he fell . Review of Resident #4's Fall Risk assessment dated [DATE] revealed the resident had a total score of 14. The Fall Risk Assessment form indicated that a total score above 10 represents high risk for falls. Review of Resident #4's Interim Care Plan revealed the resident was at risk for falls and bed/chair alarms were used as an intervention. Review of the Care Plan revealed a risk for falls was identified as a problem area. Interventions and approaches were listed on the care plan and included to ensure any safety devices ordered were in place and functioning properly every shift. Review of Resident #4's Treatment Record for June 2013 revealed Bed alarm to bed (clip) and Clip alarm to chair. The alarms were not signed for on the 7 AM - 7 PM shift for 6/10/13 when reviewed at 5:05 PM. On 6/10/13 at approximately 4:05 PM Resident #4 was observed to stand up from her wheelchair across from the nurse's station and fall. The surveyor informed Registered Nurse (RN) #2 and Certified Nurse Aide (CNA) #3 at the nurse's station that the resident had fallen. Resident #4 was noted to have a clip alarm dangling from her/his clothing but no alarm was sounding. During interview on 6/10/13 at approximately 4:19 PM RN #2 stated that Resident #4's alarm was not turned on. During interview on 6/10/13 at approximately 4:22 PM CNA #3 stated that if the alarm was turned on it would have sou… | 2016-06-01 |
| 8253 | 8253 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2013-06-18 | 309 | G | 1 | 0 | B96711 | **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 provide the necessary care and services to maintain the highest practicable physical well-being. Resident #1 was found on the floor beside her/his bed with the bed alarm sounding. The x-ray's obtained related to the fall were reported to a nurse as negative for a fracture, the x-ray's in fact showed a fractured wrist and hip. The facility failed to timely address Resident #1's injury. The findings included: Review of the facility investigation summary stated that a nurse received a verbal negative x-ray result called in to her/him for Resident #1. Because s/he received a negative verbal report, s/he did not thoroughly read the written reports when they arrived, instead placing them in the physician's box for review. Review of Resident #1's Nurse's Notes from 5/4/13 through 5/6/13 revealed the following: 5/4/13 8:00 AM indicated the resident was observed lying on his/her right side on the floor in his/her room beside the bed and the bed alarm was sounding. The nurse assessed the resident for injuries and noted the resident cried when moving his/her upper and lower right extremities. A new order for x-ray of the right side was received. 12:00 PM x-ray of resident's right side and the resident was medicated for pain. 3:00 PM x-ray results were back and no fracture was noted to the right side, the resident was medicated for pain. 10:00 PM Resident #1 was medicated for pain to the right side of the body. Tender to touch or move. 5/5/13 4:00 AM attempted to give [MEDICATION NAME] but refused to take. Appears in much pain during ADL's. 6:00 PM Resident in bed resting with eye's closed. Rt (right) side tender to touch. Pt (patient) medicated x 2 @ 7:00 AM and 2:00 PM with some effectiveness. Pt is unable to mover his/her (RLE) right lower extremities without having pain. 5/5/ - 5/6/13 at 8:00 PM medicated for pain and at 1:45 AM the doctor notified of… | 2016-06-01 |
| 8254 | 8254 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2013-06-18 | 328 | G | 1 | 0 | B96711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews, the facility failed to ensure that one of one sampled residents reviewed with a [MEDICAL CONDITION] received appropriate care and services. The facility failed to implement interventions timely to prevent dislodgement of the [MEDICAL CONDITION] cannula for Resident #7. The findings included; The facility admitted /readmitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had short and long term memory problems. Review of the hospital Discharge Summary dated 4/23/13 revealed Resident #7 initially was treated at the hospital for a decline in mental status. Imaging on day 2 demonstrated an increase in ventricular size ([DIAGNOSES REDACTED]), and the resident was transferred for neurosurgical care. The resident underwent [REDACTED]. The resident required reintubation within 48 hours for hypoxic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], and subsequently required a [MEDICAL CONDITION] on 4/2/13. According to the summary, On date of discharge, (Resident #7) is alert [MEDICAL CONDITION]. (S/he) is able to speak a few words and follow commands with the LUE (left upper extremity). (S/he) has an old right [MEDICAL CONDITION] as well as facial weakness.[MEDICAL CONDITION] in place with no plans to decannulate given poor functional status and mental status . Review of nursing facility documentation revealed a Daily Skilled Nurse's Note dated 4/26/13 at 10:00 PM, which included information that the suction catheter would not go into [MEDICAL CONDITION] the inner or outer cannula with resistance met at every attempt. Noted [MEDICAL CONDITION] turned to the R(ight) side instead of forward, this was different from 2 days ago. Outer cannula head or neck plate was not flush to the skin and outer cannula was showing protruding out of the [MEDICAL CONDITION] opening in a R(ight) direction instead of straight out.… | 2016-06-01 |
| 9050 | 9050 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2012-05-15 | 247 | D | 1 | 0 | 138B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review and interview, the facility failed to notify, 1 of 2 sampled residents with a bed hold, before the resident's room in the facility was changed. Resident #1 was discharged to the hospital on [DATE] and the family requested a bed hold; on 4/7/12 Resident #3 was placed in Resident #1's bed without notification to the family and/or resident. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to a private room. The Nurse's Note for 4/6/12 stated at 12:30 PM, the family was in and concerned the resident was not doing well. "Family request that pt (patient) be sent to the hospital." The physician was notified and the resident was sent to the hospital. The 12:00 midnight note stated, "has not returned from ...ER. Called ER resident was admitted ." Review of the Admission information on the medical record included a Bed Hold Policy. The policy stated, "... if the Resident is admitted to a hospital for treatment. The facility must be notified with the intentions of the bed hold as soon as the Resident is admitted to the hospital. The Resident/Resident Representative may pay the private rate ...per day to hold the bed. Otherwise, the bed is released and the Resident may be admitted to the first available bed..." Review of the Statement of Account, revealed the resident was charged for a bed hold from 4/6/12 (date of hospitalization ) through 4/10/12. Review of correspondence between the Administrator and the resident's family included an e-mail dated 4/9/12, confirming the resident had a bed hold. On 4/10/12 the family sent an e-mail to the Administrator stating the resident would no longer need the services of the facility. The correspondence included a statement that the family picked up the resident's belongings from a staff member, "as room... had been assigned to a new resident." The facility admitted resident #3 o… | 2015-08-01 |
| 9377 | 9377 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 514 | D | 0 | 1 | HRMY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews, the facility failed to accurately document 1 of 14 sampled residents reviewed for medication administration. Resident #11 Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #11 on 11/27/09 with [DIAGNOSES REDACTED]. Record review on 7/26/11 revealed a July 11 monthly cumulative order that indicated resident had a change in medication [MEDICATION NAME] 20 milligrams. Further record review revealed a physician order [REDACTED]. O. (Per Oral) @ (at) HS (Hour of Sleep)". Review of the June 11 MAR indicated [REDACTED]. The July MAR indicated [REDACTED]. An interview on 7/26/11 at approximately 11:55 PM with LPN (Licensed Practical Nurse) #2 revealed there had been no change in the order for [MEDICATION NAME] at 20 milligrams for Resident #11, and there was no documentation on the Medication Administration Record [REDACTED]. An interview on 7/26/11 at 12:10 PM with LPN #1 confirmed there had been no change in the physician's orders [REDACTED]. LPN #1 and #2 located the medication card for [MEDICATION NAME] for Resident #11 and stated the medication was given but not documented. This surveyor requested the pharmacist on the team to investigate the medication concern further. Review of the resident's medications in the medication cart revealed a medication punch card containing [MEDICATION NAME] 500 mg ER tablets and a separate medication punch card containing [MEDICATION NAME] 20 mg tablets. Review of the Medication Administration Record [REDACTED]. A call to Agape Pharmacy on 7/26/11 at 1:15 PM confirmed that a separate punch card of medications ([MEDICATION NAME] 500 mg ER and [MEDICATION NAME]) was sent to the facility (Agape Rock Hill) in both June and July. During an interview on 7/26/11 at 1:45 PM, the physician who ordered the medication stated that the [MEDICATION NAME]/[MEDICATION NAME] combination is available in a single medica… | 2015-05-01 |
| 9378 | 9378 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 248 | D | 0 | 1 | HRMY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review, the facility failed to provide an ongoing activity designed to meet the needs of low functioning residents. Resident #4 and Resident #9 were not provided structured 1:1 activities that met their needs based on 2 of 2 residents observed for 1:1 activities. The findings included: Resident #4 was admitted with End-stage Dementia, [MEDICAL CONDITION], Adult Failure to Thrive, Hypertension, Type II Diabetes, and Dehydration. On 7/25/11 at 12:18 PM, Resident #4 was observed in bed with legs near his chest mumbling to himself and moving in the bed. On 7/25/11 at 2:10 PM until 3:30 PM, the resident was observed in the same position in bed. On 7/25/11 at 5:30 PM, the resident was observed in a gerichair in his room with his wife sitting next to him. On 7/25/11 and 7/26/11 during repeated random observations, the resident was observed having no structured activities. On 7/25/11 at 5:30 PM, an interview with Resident #4's wife was conducted. She stated that in the past the resident was always a very social person. He loved being around children and always sang in church. On 7/25/11 at 1:00 PM, a review of the residents care plan and activity progress notes were conducted. Resident #4's interim care plan dated 4/16/11 stated that the resident lacked social interaction and stays in his room. The goal was to provide "sensory stim (stimulation) wkly (weekly) as tolerated". The comprehensive care plan dated 3/24/11 had no activity care plan provided for the resident. Review of the activity progress notes dated 6/20/11 stated "He prefers to stay in bed in room to receive daily visits from wife. When up OOB (out of bed) in w/c(wheelchair) resident has attended some activities this quarter passively. Life Enrichment will provide in room stim as desired and tolerated well". Activity Progress Note dated 7/14/11 stated that the residents wife "visits him almost daily for several hours f… | 2015-05-01 |
| 9379 | 9379 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 279 | D | 0 | 1 | HRMY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to develop a comprehensive care plan to address the psychosocial needs of 2 of 2 sampled residents that were identified as needing in room one to one activities. (Resident #4 and #9) The finding included: The facility admitted Resident #9 on 6/28/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 revealed a comprehensive care plan with a problem date of 7/11/11 that indicated resident had a potential for social isolation due to needed contact precautions and room isolation. The approaches were to provide in room activities and 1 to 1 when requested and as needed. Further record review revealed an activity evaluation that indicated the resident's current activity interest included Animals/Pets, Exercise, Music, Religious Services and Sing-Alongs which was not addressed in the care plan . The care plan did not address how often in room activities would take place. The resident's current activities of interest were not addressed on the care plan. An interview on 7/26/11 at approximately 2:10 PM with the AD (Activity Director) confirmed the findings. Resident #4 was admitted on [DATE] with End-stage Dementia, [MEDICAL CONDITION], Adult Failure to Thrive, Hypertension, Type II Diabetes, and Dehydration. On 7/25/11 at 12:18 PM, Resident #4 was observed in bed with legs near his chest mumbling to himself and moving in the bed. During repeated observations on 7/25 and 7/26 there was no observation nor documentation of the resident recieving structured activities. On 7/25/11 at 1:00 PM, a review of the residents care plan was conducted. Resident #4's interim (Admission) care plan dated was 3/24/11 stated that the resident lacked social interaction and stayed in his room. The goal was to provide "sensory stim(stimulation) wkly (weekly) as tolerated". The comprehensive care plan alsodated 3/24/11 and last updated on 6/22/11 had no activity care plan provided for th… | 2015-05-01 |
| 9380 | 9380 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 280 | D | 0 | 1 | HRMY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, Resident #2, an interviewable resident, was not invited to attend or participate in his planning care and treatment meeting. ( 1 of 4 interviewable residents reviewed r/t care plan meeting attendance.) The findings included: The facility admitted Resident #2 on 5/19/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 of the Minimum Data Set 3.0 dated 6/1/11 revealed under Section C0500 a BIMS Score (Brief Interview for Mental Status) of 14, C0700 Short Term Memory OK, C0800 Long Term Memory OK. A score of 13-15 = Cognition in tact. The facility had deemed this resident competent to make his own decisions and interviewable. Therefore Resident #2 was selected for an individual resident interview. During the interview 7/25/11 at 2:30 PM, the Resident was asked if he had been notified or had attended any care plan meetings where the staff reviewed a plan for meeting his care and treatment needs. The Resident stated he did not attend and knew nothing about it. An interview with Social Worker #1 on 7/26/11 at 2:30 PM revealed that the MDS (Minimum Data Set) Coordinator would schedule , or review the plan by phone if family could not attend. If the resident was competent but did not attend the meeting, then the Coordinator would go to the resident's room to review the care plan. Documentation in the medical record revealed "done by phone" on 6/1/11. The Social Worker stated the coordinator called the resident's wife to review the care plan. No documentation could be found to show that the competent resident (able to make his own decisions) was ever invited or informed about his care plan. | 2015-05-01 |
| 9381 | 9381 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 333 | D | 0 | 1 | HRMY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that residents remained free from significant medication errors. Resident #3, one of fourteen residents reviewed for medications, did not receive [MEDICATION NAME] as ordered. The findings included: The facility admitted Resident #3 on 6/13/11 and readmitted him on 7/15/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 revealed cumulative physician's orders [REDACTED]. One entry revealed an order for [REDACTED]. The medication had been scheduled for 9:00 AM only. Review of Physician's Telephone Orders revealed an order dated 7/15/11 which said to "Hold [MEDICATION NAME] 20 mg". A subsequent Telephone Order dated 7/20/11 stated "PT (Patient) may start [MEDICATION NAME]". Review of the July 2011 Medication Record revealed an entry for "[MEDICATION NAME] 20 mg (1) PO Q 8 hrs, On hold per Pharmacy". The medication had been initialed as having been given once daily at 9:00 AM on 7/20, 7/21, 7/22, and 7/25 instead of every 8 hours as ordered. On 7/23 and 7/24, the nurse's initials had been circled for the 9:00 AM dose which indicated the resident had not received any [MEDICATION NAME] for those two days. Documented on the back of the Medication Record were entries for 7/23 and 7/24 which stated "[MEDICATION NAME] on hold, pharmacy". During an interview on 7/25/11 at 6:10 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the cumulative July physician's orders [REDACTED]. When asked what [MEDICATION NAME] was for, she stated that [MEDICATION NAME] was another name for [MEDICATION NAME] and that the resident used this medication to improve his [MEDICAL CONDITION] function. When asked if the medication had been on hold on 7/23 and 7/24, LPN #1 stated it hadn't, and that the medication had been available and in the medication cart at that time to be given. During an interview on 7/26/11 at approximately 2:00 PM, the residen… | 2015-05-01 |
| 9382 | 9382 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-07-26 | 371 | F | 0 | 1 | HRMY11 | On the days of the survey, based on observation and interview, the facility failed to store and serve food under sanitary conditions. Multiple resident meal trays had metal exposed around the edges; plate lids were visibly worn; staff food was stored with resident food. A meal plate was removed from the kitchen, returned and placed back on the steam table. The findings included: On 7/26/11 at 11:30 AM trayline observations were conducted. A tray was observed being placed on the first tray cart. The tray cart was taken out of the kitchen and brought to the floor. Ten minutes later a dietary staff member returned with a tray from the tray cart stating that the resident was going to eat in the dining room. The covered plate of food was placed back on the steam table. On 7/26/11 at 1:25 PM, a tour of the kitchen was conducted with the RD (Registered Dietitian). During the tour it was observed that at least 30 trays had metal exposed on the corners of the tray. Plate lids were visibly worn around the edges. Staff food was observed in the hot box next to resident food. On 7/26/11 at 1:40 PM, an interview with the RD was conducted who confirmed the findings. | 2015-05-01 |
| 9643 | 9643 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2011-10-25 | 280 | D | 1 | 0 | MXVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on observations, records review and interviews, the facility failed to ensure 2 of 8 sampled residents' care plans were reviewed and revised to reflect the current care needs of each resident. Resident #1 was diagnosed with [REDACTED]. Diff) and placed on isolation precautions. The care plan was not updated to reflect the resident's status. Resident #2 was observed to be on contact precautions. The care plan was not updated to reflect the precautions. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 10/24/2011 at 10 AM, revealed a sign on the door indicating Contact Precautions. A container was noted outside the door with gowns and gloves. Review of the physician's orders [REDACTED].#1 had an order for [REDACTED].#1 was prescribed [MEDICATION NAME] three times daily for C.Diff and was started on contact precautions. Review of the Laboratory Data revealed Resident #1 had a positive [DIAGNOSES REDACTED] sample reported on 10/20/2011. Review of the Care Plan revealed it had not been updated to reflect the new [DIAGNOSES REDACTED]. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 10/24/2011 at 10 AM revealed a sign on the door indicating contact precautions. A container was noted outside the door with gowns, gloves and shoe covers. Review of the the Laboratory Reports revealed a report dated 9/11/2011 regarding a culture taken from a breast wound which was positive for Acinetobacter Baumannii. Resident #2 was noted to scratch his skin constantly causing open abrasions and wounds Record review revealed Resident #2 was admitted to the hospital on [DATE] the Discharge Summary dated 10/11/2011 revealed Resident #2 was treated for [REDACTED]. "... It was noted that there was likely an underlying [MEDICAL CONDITION]/allergic component to the patient's skin condition, as he had increased eosinophils of … | 2015-02-01 |
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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 );