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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10266 | 10266 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 281 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of acceptable standards of practice for licensed staff , the facility failed to assure for 1 of 2 residents reviewed for accurate documentation related to a [MEDICAL TREATMENT] site that the documentation was thorough and accurate as entered. Resident #4 had documentation of thrill and bruit checks after the shunt site was changed and the physician discontinued the order. The findings included: The facility admitted Resident #4 on 6/26/09 with the following Diagnoses: [REDACTED]. The record review on 4/12/10 revealed a physician's orders [REDACTED]. Further review revealed another order written on 11/5/09 for removal of infected [MEDICAL TREATMENT] catheter and replacement of [MEDICAL TREATMENT] catheter- a tummeled catheter due to permanent placement access. During an interview with Registered Nurse (RN) #1 on 4/12/10 he/she stated " a thrill and bruit is not checked because the resident has a catheter in her right chest, the other site was removed." The nurse's notes revealed that Licensed Practical Nurse (LPN) # 2 documented in the notes "thrill felt and bruit heard" on the following dates 3/11/10, 3/13/10, 3/27/10 and 4/10/10. LPN #1 documented in the nurse's notes on 3/13/10 "bruit and thrill felt". LPN #3 documented in the nurse notes on 3/30/10 "thrill felt and bruit heard". During an interview with LPN #1 on 4/12/10 at 4 PM, when asked how he/she checked for a thrill and bruit, he/she stated "I just put the stethoscope above the catheter and hear a "LUB-DUB". During an interview with LPN #2 on 4/12/10 at 4:15 PM when asked how he/she checked for a thrill and bruit, he/she stated " you have to check that in the arm, but hers is in the chest". When ask why he/she documented that the thrill and bruit was checked, the LPN stated "I don't know". | 2014-01-01 | ||
| 10267 | 10267 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 315 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy and procedure, the facility failed to provide appropriate catheter care for one of one catheter treatments observed. The Registered Nurse (RN) failed to properly anchor the catheter tubing during Resident # 3's catheter care. The findings included: The facility admitted Resident #3 on 7/27/09 with the following Diagnoses: [REDACTED]. During the catheter care observation on 4/13/10 at 9:15 AM RN #2 failed to secure the tubing to prevent pressure from tugging of the suprapubic catheter while cleaning, then drying the tube. At 9:20 AM on 4/13/10 during an interview with RN #2 he/she stated when ask about anchoring the tube "I didn't anchor it because its in the stomach." The facility policy titled Catheter Care, Suprapubic, stated under Procedure #11 "Gently grasp the catheter with non-dominant hand and use clean wash cloth to work down the tubing approximately 6 inches" | 2014-01-01 | ||
| 10268 | 10268 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 323 | E | THIH11 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Three bathrooms in the common area observed to be used by residents had no call light system in place. The findings included: A random observation on 4/12/10 revealed a female resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. Another random observation on 4/13/10 revealed a male resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. An inspection of the bathrooms 1. located on the back hall next to the main dining room, 2. the bathroom directly across from the main dining room and 3. the bathroom located between the beauty shop and the activity room, all revealed no call light system in place. During an interview with the Director of Nursing (DON) on 4/13/10 at 11:40 AM, he/she confirmed that "these bathrooms are used by everyone, staff, visitors and residents". The DON stated that "the residents are assisted". When he/she was informed of the observations of residents using the bathroom alone, he/she stated "well we do have some that can go by themselves." | 2014-01-01 | ||
| 9914 | 9914 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2010-07-07 | 246 | D | 0 | 1 | 56KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to use appropriate methods to accommodate 1 of 1 sampled resident's need for a bed that would be the correct length. The findings included: The facility admitted Resident #2 on 9/21/09 with [DIAGNOSES REDACTED]. During the initial tour on 7/6/10 at approximately 11:30 AM, the resident was observed in bed with his feet extended over the foot of the bed. During all days of the survey, the resident was observed in bed in the same situation , either with a folded towel or pillow under his feet. In an interview with a family member on 7/6/10 at 8:25 PM, he/she stated that when visiting, he/she would try to pull the resident up in order to be more comfortable. In an interview with the Administrator, Director of Nursing and Nursing Consultant on 7/7/10 at 10:35 AM, they stated that the resident would slip down in the bed. A later observation revealed a blue foam wedge between the end of the mattress and the foot of the bed. with the resident's feet on the wedge. | 2014-09-01 |
| 9915 | 9915 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2010-07-07 | 281 | E | 0 | 1 | 56KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility nursing staff failed to provide care that met professional standards of practice for one of four sampled resident's reviewed with sliding scale insulin. The nursing staff failed to clarify incomplete sliding scale insulin orders and failed to transcribe the correct sliding scale insulin to the Diabetic Flow Chart for Resident # 9. Furthermore, the nurses failed to identify the discrepancy between the MAR (Medication Administration Record) and the Diabetic Flow Chart for Resident # 9 . In addition, the nursing staff failed to correctly reconcile Physician orders [REDACTED]. The findings included: The facility admitted Resident # 9 on 3/25/09 with [DIAGNOSES REDACTED]. On 7/6/10 review of the resident's clinical record revealed that the resident had returned to the facility on [DATE] with readmission orders [REDACTED]= 2 units, 201-250 = 4 units, 251- 300 = 6 units, 301-350 = 8 units. There were no additional orders for what to administer if the resident's blood sugars were above 350. Review of the June MAR (Medication Administration Record) revealed that the new sliding scale insulin order had been correctly transcribed to the MAR and nine different nurses had initialed that the sliding scale had been administered twice a day. Review of the Diabetic Flow Chart revealed that the nursing staff had failed to update the chart to reflect the new sliding scale parameters and the nurses had administered the insulin following the old parameters. Further review of the chart revealed that there were no additional orders written related to sliding scale insulin. Interview with LPN # 1 on 7/6/10 at approximately 2:45 PM revealed that he/she had written the readmission orders [REDACTED]. When questioned related to the sliding scale parameters stopping at 350, he/she stated that he/she did not clarify the order and that if the blood sugar was above 400, the nurse should call the … | 2014-09-01 |
| 10142 | 10142 | GLORIFIED HEALTH AND REHAB OF GREENVILLE, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2010-07-07 | 309 | D | KOJZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide care and services as ordered by the physician. One of fourteen residents reviewed for care and services, Resident # 8, did not receive a follow-up with the oncologist to get biopsy results as ordered. The findings included: The facility admitted Resident # 8 on 6/14/10 with [DIAGNOSES REDACTED]. Record review on 7/6/10 at 2:30 PM of the accumulative physician's orders [REDACTED]. ___ (1) wk (week) for biopsy results". Review of the Physician Discharge Summary dated 6/14/10 on 7/6/10 at 2:37 PM revealed under "Hospital Course", that Resident # 8 was admitted with AMS (Altered Mental Status) s/p (status [REDACTED]. [MEDICATION NAME] on 6/10 with ROSE (Rapid On-Site cytopathologic Examinations) revealing malignancy...Heme/Onc (Hematology/Oncology) was consulted and recommended breast mass biopsy. This was performed on 6/14 by general surgery and final pathology/results pending. (Resident #8) is scheduled to follow up with Dr. ___ in 1 week for these results and to initiate plan of care... (She/He)does need quick follow up for biopsy results with Heme/Onc as this looks like [MEDICAL CONDITION] from preliminary results. (She/He) may be a possible Hospice candidate given her PMH (Primary Medical History) of dementia and other co-morbid conditions". Review of the Physician's Progress Notes, Nurses Notes, and Laboratory results on 7/6/10 revealed no mention of the breast mass biopsy results or an office visit. During an interview on 7/7/10 at 9:15 AM, RN (Registered Nurse) #1 reviewed the June 2010 accumulative physician's orders [REDACTED]. During an interview on 7/7/10 at 11:20 AM, Unit Clerk #1 was asked if they used an appointment calendar to keep track of residents' appointments. She/He stated that Resident #8's appointment was not on her calendar. When asked about how Resident #8 would have been transported to the appointment, she/he stated that EMS… | 2014-04-01 | ||
| 9982 | 9982 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 371 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions as evidenced by dietary staff not wearing hair restraints appropriately. The findings included: Observations on 7/19/10 at approximately 10:45am revealed 1 dietary aide whose hair restraint did not cover the front third of the head. Observations on 7/20/10 at approximately 12:05pm revealed the dietary aide, who was plating food on the trayline, the hair restraint did not cover the front half of the head. An aide who was placing the plates of food on the trays, the hair restraint did not cover the front third of the head. An aide who was a runner between the trayline in the main kitchen and the main dining room, the hair restraint did not cover the braids on the sides of the face. Interview with the Dietary Manager on 7/20/10 at approximately 12:25pm confirmed that the Aides were not wearing the hair restraints so that the restraints covered all the hair. | 2014-08-01 |
| 9983 | 9983 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 221 | D | 0 | 1 | 2B2D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to assure that one of two sampled residents reviewed for restraints was free from any physical restraint not required to treat the resident's medical symptoms. Resident # 20 was observed using a concave mattress. There was no evidence provided that a restraint assessment was completed, nor consent obtained for the use of the mattress. The findings included: The facility admitted Resident # 3 with [DIAGNOSES REDACTED]. During the initial tour of the building on 7/19/10, Resident # 3 was identified as using a concave mattress. A mattress with elevated sides was observed on the resident's bed. Record review conducted on 7/21/10 revealed a physician order [REDACTED]." An Occupation Screen dated 7/6/09 stated: "Resident suffered fall attempting to tx(transfer) out of bed. Res. (Resident) has low bed c (with) rails. Pt. (patient) would benefit from concave mattress as reminder to not attempt to tx. unassisted,..." The Director of Rehabilitation also stated the resident fell again on 7/15, proving that the mattress did not "prevent" the resident from getting out of bed. However, s/he verified that the facility had not considered the concept that a concave mattress could meet the definition of a restraint and no initial or subsequent restraint evaluation or consent had been obtained for its use. After the resident fell on [DATE], no subsequent evaluation was conducted related to the safety of continuing the device. A general review of the resident's physical capabilities from 7/09- 7/10 revealed the resident's ability to transfer and ambulate had fluctuated during the past year. The resident's ambulation capability reached approximately 150 feet with minimum assist and rolling walker and the ability to transfer with minimum assist with contact guarding (8/22/09 therapy discharge notes). On 7/21/10 at 9:30AM, an interview with Certified Nursing Assist… | 2014-08-01 |
| 9984 | 9984 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 441 | D | 0 | 1 | 2B2D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility provided infection control policy for hand hygiene (8/7/09), a facility staff member was observed to not follow facility standards related to handwashing/gloves use during the completion of a tube flush for Resident # 3. The staff member donned gloves at the start of the procedure and contaminated clean areas by failing to change gloves and/or wash hands. (One of seven treatments observed for infection control compliance.) The findings included: The facility admitted Resident # 3 on 9/27/08 with [DIAGNOSES REDACTED]. Resident # 3 was located in a room with three additional resident beds, with one community sink. On 7/19/10 at 2:45PM, an observation was conducted of Licensed Practical Nurse (LPN) # 2 performing a gastric tube flush for Resident # 3. The LPN was observed to wash his/her hands and turn on the light above the resident's bed, partially pull the bedside curtain, and apply gloves. While wearing gloves, the LPN turned the faucet on/off three times to measure the water to be used for the flush. He/she pulled the bedside curtain closed, exposed the gastric tube site, raised the head of the bed, and checked for gastric tube residual. The LPN opened the bedside curtain, returned to the sink, still wearing the same pair of glove. He/she turned on the water and rinsed the syringe. Continuing to wear the same gloves, the bedside curtain was opened, and the nurse administered the tube flush via gravity. The resident was re-draped, the bedside curtain opened, and the syringe/plunger washed and returned to storage. The LPN then removed the gloves worn during the process and washed his/her hands. On 7/21/10, the observation was shared with the Director of Nursing and the concerns not disputed. Facility policy for infection control (8/7/09) stated: "Gloves or the use of baby wipes are not a substitute for hand hygiene." | 2014-08-01 |
| 9985 | 9985 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 253 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observations and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior. Throughout the facility there were observations of multiple wheelchairs and gerichairs with cracked and/or torn arm pads unable to be adequately cleaned or sanitized. On 3 of 5 units there were shower chairs coated with a reddish-brown and/or black filmy substance. The findings included: During general dining observations in the main dining room on 7/19/10 at 12:28 PM, three wheelchairs were noted with cracked or torn arm pads. Observations in the small dining room next to the 400 Unit Nurses Station on 7/19/10 at approximately 12:35 PM revealed 1 gerichair and 3 wheelchairs with cracked/torn arm pads. Based on these observations, a general tour of the facility was conducted on 7/20/10 beginning at 3:45 PM. Eight wheelchairs/gerichairs were noted with cracked/torn arm pads. - Outside Room 305 (Geri-chair with both arms torn). - In the small dining room next to the 300 Unit Nurses Station (3 residents sitting in wheelchairs with one or both arm pads cracked). - Between the Business Office and Room 501 (2 wheelchairs with torn arm pads) - Between the water fountain and Room 503 (1 wheelchair with cracked arm pads). - In Room 407 (1 resident sitting in a wheelchair with a cracked arm pad). During a walking tour of the facility on 7/21/10 between 8:37 AM and 9:15 AM, the following observations of wheelchairs and gerichairs with cracked or torn arm pads were verified by the Maintenance Supervisor, Housekeeping Supervisor, and the Regional Supervisor for the contracted Housekeeping Service: - There were 2 wheelchairs and 1 gerichair in the 300 Unit hall with cracked/torn arm pads. - In the small dining room next to the 400 Unit Nurses Station there were residents sitting in 2 wheelchairs with cracked/ torn arm pads. - There was one wheelchair outside room 408 and one wheelchair in room 505 with cracked/torn arm pads. - In the 500 Unit hall … | 2014-08-01 |
| 9986 | 9986 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 356 | C | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to post complete staffing data. The facility failed to post the number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the actual hours worked by category for each shift on the Staff Posting forms. The facility also failed to post the data in a prominent location readily accessible to visitors and residents as required. The findings included: Observation on 7/19/10 at approximately 5:20 PM and on 7/20/10 at approximately 10:50 AM revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting forms for the 7:00 AM - 3:00 PM shift, the 3:00 PM - 11:00 PM shift or the 11:00 PM - 7:00 AM shift on those dates but were posted as "Licensed Nurses." During observations throughout the survey, the Staff Posting forms were posted behind the nursing stations and not displayed in a prominent location readily accessible to visitors and residents. Copies of the Staff Posting forms for the last 30 days were requested on 7/20/10. Review of these forms revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting form on any of these dates as required but were posted as "Licensed Nurses." Review of the Staff Posting forms for the last 31 days revealed that on all of the last 31 days, the Staff Posting forms indicated 6 nurses for the 3:00 PM - 11:00 PM shift. Review of the 24 Hour Assignment sheets revealed that on 22 of the last 31 days, 6 nurses worked from 3:00 PM - 7:00 PM but only 5 nurses worked from 7:00 PM - 11:00 PM. During an interview on 7/21/10 at approximately 11:30 AM, the Director of Nursing (DON) confirmed that the posting did not list the Licensed Nurses by category or include the actual hours worked. The DON also confirmed that the Licensed Nurses worked 12 hour shifts and that the number of nurses that worked between 3:00 PM - 7:00 PM and 7:00 PM - 11:00 PM was different and was not reflected on the Staff Postin… | 2014-08-01 |
| 9987 | 9987 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 167 | C | 0 | 1 | 2B2D11 | On the days of the survey, based on observations and interview, the facility failed to place the most recent state survey results in a location readily accessible to residents and visitors, and there were no notices posted regarding the availability of the survey results. The findings included: Observation on 7/19/10 at approximately 12:45 PM revealed a white binder entitled "DHEC (Department of Health and Environmental Control) Survey" sitting on the receptionist's desk back behind a lamp. The survey results were not readily accessible to residents or visitors. Observation on 7/20/10 at 11:35 AM revealed the receptionist sitting at a desk near the entrance of the facility. The Director of Nursing (DON) was standing next to her/him. A white binder entitled "DHEC Survey" was sitting on the desk behind a lamp a couple feet away to the right and behind where the receptionist was sitting. When questioned by the surveyor if anyone had asked to see the survey results, the receptionist stated that sometimes residents or visitors would ask to see them. When questioned if the survey results were readily accessible where they were located if someone had to ask to see them, the DON moved the survey results to the front of the desk below the countertop. During a general tour of the facility on 7/20/10 from 3:45 PM to 4:45 PM, observations revealed there were no notices posted regarding availability of the most recent state survey results. | 2014-08-01 |
| 9988 | 9988 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 468 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side. The findings included: During a walk through of the facility on 7/20/10 beginning at 3:45 PM and during a tour with the Maintenance Supervisor on 7/21/10 at 8:37 AM, loose and/or missing handrails were observed and confirmed in the following areas: - Between the lobby and the 100 Hall Nursing Station there were no handrails on one side. The handrails on the other side were loose. The hall exiting to the courtyard had no handrails on either side. - Between Room 111 and the exit door, there was approximately 6 feet of handrail missing. - Between the Men and Women's Shower Room across from Room 200, there was a handrail missing. - There was a loose handrail outside of Room 208. - There was a loose handrail between the Men/Women's Restroom and Shower on the 300 Hall. - There was an 11 foot section of handrail that was missing in the breezeway near the 400 Hall Nursing Station. - There were several sections of handrail missing in the hall leading to the dining area between the 400 and 500 Halls (7 feet on one side, 4 feet on the other, and one full section of 11 feet on one side). - There were no handrails for approximately 3 feet outside the Social Services Office on the 500 Hall. - There were no handrails between Room 504 and the fire door for approximately 2 feet. | 2014-08-01 |
| 10278 | 10278 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 425 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy, supplying medications to the facility, failed to assure the accurate administration of all drugs for 1 of 6 residents observed during medication pass. Resident A with a physician's orders [REDACTED]. The findings included: On 7/27/10 at 8:50 AM during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #4 was observed to measure Miralax Powder to the 15 milliliter mark in a medication cup used to measure liquid medications. The Miralax Powder was dissolved in 7 ounces of water and administered to the resident along with 8 other medications. Reconciliation of medication pass for Resident A revealed a current physician's orders [REDACTED]. DX (diagnosis) CONSTIPATION". The identical physician's orders [REDACTED]. All of the orders were signed by the physician without clarifying the ambiguous dosage. Further review revealed that the Physician's admission orders [REDACTED]. Dx Constipation". During an interview on 7/28/10 at 8:40 AM, the pharmacist at the pharmacy supplying the medications to the facility, stated that the pharmacy did not have the original order for the Miralax Powers (written 1/20/04) on hand. She/he stated that, on the pharmacy side, they have 17 Gms in 8 ounces of water as the standard (manufacturer's recommended) dose for Miralax and confirmed that the dosage on the monthly orders, printed by the pharmacy, was not clear. She/he further stated that, if there was an error, it was the pharmacy's fault. During an interview on 7/28/10 at 8:47 AM, LPN #4 stated that the pharmacist came to the facility yesterday (7/27/10) at about 5 PM, after the observation of medication by this surveyor the morning of the same day, and changed the dose for the Miralax on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. | 2014-01-01 | ||
| 10279 | 10279 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 314 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the product insert sheet for Santyl/facility policy for the application of a [MEDICATION NAME] product, the facility failed to assure that one of two sampled resident's reviewed for pressure ulcer care received appropriate treatment and services. During observation of the pressure ulcer treatment for [REDACTED]. Facility staff was unaware if the pressure relieving mattress in use was appropriately set for the resident's use. The findings included: The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/27/10 at 9:10am, an observation of the resident's pressure ulcer treatment was conducted. During the the procedure, the wound care nurse was observed to clean the outside raised edge of the pressure ulcer but not clean the wound bed itself. The wound bed was noted to contain slough and tunneling was noted. Following the treatment, the wound care nurse was questioned as to why the wound bed was not cleaned. S/he stated s/he did not want the spray the "collect" where the wound was undermined and did not want to injure the wound bed by having to pat it dry. S/he also stated s/he felt the use of Santyl cleaned the wound bed when the previous dressing was removed. Review of the product insert sheet from Santyl revealed the manufacturers recommendation stated to clean the wound bed prior to the application of Santyl. The instructions stated the wound bed should be cleansed prior to application.. remove as much loose debris as possible, gently cleanse the wound bed with saline or wound cleanser followed by saline each time the dressing is changed. Additionally, the facility policy also stated the wound bed should be cleansed prior to the application of a [MEDICATION NAME] product. Also following the completion of the treatment, the facility wound care nurse was questioned related to the use of the pressure relieving mattress wh… | 2014-01-01 | ||
| 10280 | 10280 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 373 | D | 1BYP11 | On the days of the survey, based on observation, interview and record review, the facility failed to identify the use of a paid feeding assistant program and failed to implement the approved program consistent with State law. The findings included: On 7/26/10, upon entrance to the facility, the Administrator stated the facility did not utilize a paid feeding assistant program. On 7/27/10, at approximately 1:30pm, the Administrator and Nurse Consultant again stated the facility did not have or use a paid feeding assistant program. During random observations during the evening meal on 7/26/10, two activity staff members were observed feeding residents in the "B" building. One resident was being fed in a small alcove in the "B" building and another resident was being fed in his/her room. Both staff members stated they were not Certified Nursing Assistants. During the noon meal on 7/27/10, the activity members were again observed feeding residents either in their rooms (building "B") or dining room (main building). Further investigation revealed the facility did have an state approved feeding assistant program. On 7/27/10 at 2PM, during an interview with the Staff Development Coordinator (SDC) , s/he stated s/he had not taught the feeding assistant program since her return to the facility 12/09 but s/he previously had taught it at the facility. S/he stated an awareness that both activity personnel had previously completed the feeding assistant program. When asked which residents a staff member who had completed the program could feed, the SDC stated they would feed "easier" residents. S/he further stated one particular activity staff member would feed "anyone she felt comfortable with...s/he would not step out of her comfort zone." A review of personnel files revealed both staff members had completed the paid feeding assistant program at the facility (in 2005 and 2007). On 7/28/10, during an interview with the Administrator it was verified that the facility was not cognizant that using trained staff members to feed r… | 2014-01-01 | ||
| 10281 | 10281 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 441 | E | 1BYP11 | **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 maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. Following observation of catheter care for Resident # 3, handwashing concerns were identified. The findings included: On 7/27/10 at 11AM, an observation of the facility laundry department was conducted. Laundry worker # 1 was observed placing soiled laundry into a washing machine. After the soiled laundry was placed, s/he was observed to remove the protective gown by pulling it over his/her head when unable to untie the strings. The same laundry worker was asked to explain the process on how to handle laundry from an infected resident. Both Laundry worker # 1 and # 2 stated they would wear two pair of gloves and put on two gowns for protection. When asked how the two gowns would be applied, they stated one frontward and one backward. A box containing 3 pillows (1 cloth and 2 vinyl covered) was observed in the soiled area. When asked how the pillows would be cleaned, Laundry worker # 1 stated one pillow would be discarded because it was torn. The other two pillows would would be cleaned the same by spraying and wiping off with a disinfectant cleaner and then dried with a towel. Review of the label of the product indicated would be used stated it was to be used for non-porous surfaces. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. The facility water temperature for personal laundry was identified as cold/warm. Appropriate chemical sanitization was used for bedding and other linens when washed. On 7/27/10 at 11:25AM, an interview was conducted with the Maintenance Supervisor, identified as in charge of the … | 2014-01-01 | ||
| 10282 | 10282 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 156 | D | 1BYP11 | **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 a Resident's responsible party's stated interest in a Do Not Resuscitate order was acted upon timely. Resident # 11's responsible party expressed interest in formulating an Advanced Directive. After the Resident was determined to lack capacity for healthcare decisions, the facility took no further action. (1 of 13 sampled resident's reviewed for Advanced Directives) The findings included: The facility last admitted Resident # 11 on 7/7/10. The resident's [DIAGNOSES REDACTED]. On 7/26/10 a review of the current medical record revealed a Social progress note dated 7/8/10 which stated: "Res (resident) has POA (Power of Attorney) copy placed on chart and no living will. RP (Responsible party) is interested in DNR (Do not Resuscitate)." On 7/14/10 two physicians documented the resident lacked capacity to make healthcare decisions. Additional Social progress notes were documented on 7/16 and 7/19/10 noting resident behaviors and family visits/contacts. However, there was no further documentation related to the resident's advanced directive status. On 7/26/10 at 4:10pm, during an interview with the nurse consultant, s/he stated the resident was a "full code." On 7/27/10 at 11am, during an interview with social services employee # 1, s/he stated once a resident's capacity has been determined, appropriate action related to the residents/responsible party stated wishes for advanced directives should "happen quickly". S/he verified no action had been taken by the facility after the resident's capacity has been determined. S/he further stated the RP had been contacted and would be coming to the facility "today" to sign the paperwork for the resident's Do Not Resuscitate status. | 2014-01-01 | ||
| 10004 | 10004 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-08-04 | 441 | E | 0 | 1 | 3N7711 | On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Observations of processing resident's personal laundry and interview with staff of the Laundry Department revealed failure to ensure personal laundry was sanitized appropriately per infection control guidelines. The findings included: On 8/4/10 at 10AM, an observation of the facility laundry department was conducted. Upon entering, observations revealed 2 of the 3 washing machines in the process of washing clothes. The washing machines had a display that identified various functions while running. One of the functions allowed display of the current water temperature. Observations of the temperature of the washing machine used for colored clothes displayed a temperature of the water at 53 degrees Farenheit . The temperature continued to read 53 degrees Farenheit on two additional reviews of the washing machine's water. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. On 8/4/10 at 10 :03 AM, an interview was conducted with the Housekeeping Supervisor, identified as in charge of the laundry. He/She confirmed the water temperature and stated no other disinfecting chemicals were used for resident's laundry. | 2014-08-01 |
| 10181 | 10181 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 441 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interviews, the facility staff failed to demonstrate appropriate knowledge related to infection control issues. The findings included: On 8/11/10 at approximately 9:30 AM during an interview with LPN # 1 when questioned what he/she would tell visitor's prior to entering a resident's room who had an order for [REDACTED]. On 8/11/10 at approximately 9:45 AM interview with Housekeeper # 1, who was responsible for cleaning a room with a "Stop See the Nurse Prior to Entering." sign was questioned what the sign meant. Housekeeper # 1 was unable to tell the surveyor why the sign was posted. When questioned if he/she would utilize any special cleaning procedures for a resident who was on contact isolation for Clostridium Difficile, he/she failed to identify to use any chemical to clean the room. On 8/11/10 at approximately 10:15 AM RN # 4 was questioned what he/she would tell a visitor prior to entering a resident's room who was on contact precautions. He/She stated that he/she was unsure what to tell a visitor. On 8/11/10 at approximately 11:00 AM, Housekeeper # 2 was questioned if he/she would use any special procedure to clean a resident's room who was on contact isolation for Clostridium Difficile, and he/she stated no. When questioned if he/she had been trained on cleaning procedures for rooms that had resident's with infection control precautions, he/she said no. | 2014-04-01 | ||
| 10182 | 10182 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 425 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 2 of 4 medication rooms. The finding included: On 8/9/10 at approximately 11:15AM, inspection of the 1 South Medication Room revealed one orange colored Emergency Box sealed with a red integrity seal and bearing an outside label which read Meclizine expired 7-27-10. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg (milligram)/ml (milliliter), 50 ml. by Hospira, Lot 68-435-DK, expired 1 [DATE] (August 1, 2010). -One Extended Phenytoin Sodium 100mg capsule lot 39 expired 8-5-10 (packaged by NCS Healthcare of SC) -Two Ciprofloxacin 500mg tablets lot BEM51B LC expired 7-2-10 (packaged by NCS Healthcare of SC) -Five Meclizine HCl 25mg tablets lot 601 EH expired 7-27-10 (packaged by NCS Healthcare of SC) These findings were verified by RN (Registered Nurse) # 1 (Floor Manager) on 8/9/10 at approximately 11:25AM who stated that the Consultant Pharmacist is supposed to check for out- of-date medications during monthly visits and was unsure whether the nurse was also responsible for checking on an ongoing basis. RN # 1 a lso confirmed that this emergency box was used to supply medications to all residents on the first floor. On 8/9/10 at approximately 1:40PM, inspection of the 2 North Medication Room revealed one orange colored Emergency Box sealed with a green integrity seal. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg/ml, 50 ml. by Hospira, Lot 68-434-DK, expired 1 [DATE] (August 1, 2010) This finding was verified by LPN (Licensed Practical Nurse) # 1 on 8/9/10 at approximately 1:50PM. LPN # 1 stated that the box had been delivered on 8/6/10 by the Pharmacy and that the green integrity seal indicated that it had not been opened since delivery. This findi… | 2014-04-01 | ||
| 10035 | 10035 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 156 | C | 0 | 1 | G5LE11 | On the days of the survey, based on record reviews and interview, the facility failed to complete 3 of 3 mandated Liability Notices. The findings included: During review of resident funds on 8/18/10, three of three mandated Liability Notices were not completed by the business office. During an interview following the review, the Business Manager confirmed that the Liability Notices were not completed. | 2014-07-01 |
| 10036 | 10036 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 315 | D | 0 | 1 | G5LE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, facility policy, and interview, the facility failed to provide appropriate catheter care for 1 of 3 sampled residents with observed catheter care. Resident #3 received catheter care without appropriate cleansing of the area surrounding the meatus and releasing the labia between attempts to clean the perineal area. The findings included: The facility admitted Resident #3 on 11/14/08 with [DIAGNOSES REDACTED]. Observation of catheter care on 8/17/10 at 3:40 PM revealed that after donning gloves, Certified Nursing Assistant(CNA)#2 attempted to spread the resident's labia and with a peri-wipe cleansed down the center. Releasing the labia, CNA #2 obtained a second wipe and placing her right hand on the mons pubis, cleansed down the center of the perineal area. Resident #3 was turned to his/her right side and using different periwipes, cleansed down the left buttock, cleansed down the right buttock, and cleansed the rectal area in an upward motion. Resident #3 was turned onto his/her back. CNA #2 removed his/her gloves, washed his/her hands, and donned gloves. The catheter was grasped at the insertion site and cleansed approximately four inches down the catheter tubing. CNA #2 removed his/her gloves, washed his/her hands, gathered the trash and disposed of the trash in an appropriate container. Review of the facility policy titled "Urinary Catheter Care", states in section IIb - 'Cleanse area of catheter insertion well using soap and water or peri-wipes and being careful not to pull on catheter or advance it further into the urethra. The facility had conducted several inservice trainings on Urinary Tract Infections during the month of March 2010 in which CNA #2 attended at least one inservice. The above observation was shared with the Director of Nursing on 8/18/10. | 2014-07-01 |
| 10037 | 10037 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 441 | D | 0 | 1 | G5LE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations and interviews, the facility presented with a soiled utility room on the North hall with the hand washing sink unaccessible due to a box of trash can liners placed on the sink and multiple over filled barrels of soiled linen which crowded the room. Soiled gloves were used to complete supra pubic catheter care for Resident #5 which was one of four catheter treatments observed. The findings include: The facility admitted Resident #5 on 03/19/09 with [DIAGNOSES REDACTED]. On 08/17/2010 at 11:30 AM Certified Nurses Assistant (CNA) #1 completed peri care and, with the same gloves on, completed supra pubic catheter care for Resident #5. After CNA #1 removed the soiled gloves and was washing her/his hands, she/he confirmed that normally the soiled gloves are removed and hands are washed, then the catheter care completed with clean gloves. During an interview with the Staff Development staff, they indicated that the catheter care and the peri-care was fine. She/ He verbalized that the gloves needed to be removed and the hands washed between peri-care and the supra pubic catheter care. After performing pressure sore treatment on 8/17/10 at 12:10 PM, Licensed Practical Nurse(LPN)#4 disposed of trash/linen in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into the room with three barrels not completely covered. LPN #4 left the soiled utility room and entered an employees' only room which appeared to be a nourishment area. After performing a tube flush on 8/17/10 at 12:57 PM, LPN #2 disposed of trash in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into room with several barrels partially covered. LPN #2 leaned over a barrel to reach the handwash sink. After performing pressure sore treatment on 8/17/10 at 4:42 PM, LPN #3 disposed of trash in the North soiled utility room. A box of trash liners was noted on … | 2014-07-01 |
| 10079 | 10079 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 431 | E | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain records of receipt and disposition of all controlled drugs in sufficient detail to ensure a determination that drug records were accurate and periodically reconciled for 3 of 7 sampled residents reviewed for the administration of controlled substances. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. The medical record documented the medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. In addition the facility failed to provide a separately locked, permanently affixed compartment for storage of discontinued controlled drugs (Schedule II and other drugs subject to abuse) which limited access to authorized personnel, in the First Floor Medication Room. (One of 2 medication rooms reviewed for medication storage). The findings included: On 8/18/10 at 8:53 AM, observation of the First Floor Medication Room revealed a locked cabinet used for storage of discontinued narcotics and other controlled medications (per the Consultant Pharmacist). The cabinet was locked but a hole was observed in the cabinet door. The hole was measured to be 20 inches from the bottom of the cabinet. The hole was large enough for this surveyor to insert a hand through the hole and inside the locked cabinet. Observation of the contents of the cabinet revealed the following multidose containers: 1 pack OxyContin CR (Controlled Release) 10 mg - 4 tablets remaining 1 pack Morphine ER … | 2014-06-01 |
| 10080 | 10080 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 281 | E | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain professional standards for the administration of controlled medications. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. Resident # 4's medical record documented medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Concerns were identified related to the disposal of controlled medications which were dispensed but refused by Resident # 19. Resident # 17 was documented as having refused his/her controlled medications without further explanation. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. (3 of 7 sampled residents reviewed for the administration of controlled substances.) The findings included: The facility last admitted Resident # 4 on 7/9/10. The resident's [DIAGNOSES REDACTED]. On 8/17/10 at 10:15AM, review of the current medical record revealed the resident was ordered by the physician to receive liquid [MEDICATION NAME] 7.5/15 milliliters (ml)- 20 ml every four hours for pain. A review of the Narcotic Sign Out Record revealed on 7/28/10 at 1800 15 ml was signed out as administered with a notation of "bottle completed". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders, physician progress notes [REDACTED]. After the concern had been brought to the attention of the facility, the nurse responsible for the administration of the medication was sent to speak to this surveyor, accompanied by the Director of Nursing and the Con… | 2014-06-01 |
| 10081 | 10081 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 441 | E | 0 | 1 | SNPY11 | On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. The findings included: On 8/17/10 a review of the facility laundry system was completed. It was revealed that only personal laundry was processed within the facility. On 8/17/10 an interview with Laundry staff member # 2, who stated s/he was the primary person responsible for personal laundry was conducted. S/he stated that personal laundry was processed using cold water. Laundry worker # 2 stated that if a resident was on isolation, s/he would use hot water. However, s/he was unaware of the water temperatures available for use within the laundry. When asked if any bleach/sanitizing type product was used for processing personal laundry, s/he stated "no". S/he also stated s/he processed the cloth napkins used by residents using hot water (unknown temperature) and no bleach. A follow-up interview with the Laundry supervisor confirmed the process used. At 12 noon, a written statement was given the surveyor stating the water temperature was not 160 degrees. On 8/18/10 at 11AM, a meeting was conducted with the Administrator at his/her request and representatives from the Laundry Supply Company responsible for processing other linens used by the facility and processed at the hospital; hospital/facility laundry representatives, facility engineers, Maintenance, and the survey team. During the meeting it was stated that the Administrator was not aware until August 2010 of the changes in the regulation. Due a personal concern, s/he had sent the information to the Director of Nursing who then sent the information to the person in charge of the laundry. However, no action had been taken until the concern was identified by the survey team. | 2014-06-01 |
| 10082 | 10082 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 280 | D | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise Resident # 15's care plan to accurately reflect the location and type of access port to receive [MEDICAL TREATMENT]. ( 1 of 1 [MEDICAL TREATMENT] resident reviewed for accuracy of care plan.) The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where e/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented " several attempts were made at an AV fistula, all failed and e/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related to any dressing checks. Continued record review on 8/18/10 revealed care plan #7 for Potential for Complications related to [MEDICAL TREATMENT]. Listed under approaches was the following: 1. Monitor/report/record to MD (Medical Doctor) prn (as necessary) [MEDICAL TREATMENT] complications such as air embolism, bleeding, decreased cardiac output, local or systemic infection. 2. check [MEDICATION NAME] site… | 2014-06-01 |
| 10083 | 10083 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 309 | D | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility had no Policies/Procedures related to Caring for the [MEDICAL TREATMENT] Resident , had no education for staff on care of [MEDICAL TREATMENT] resident in 2009 nor 2010, and had no documentation of any assessment of the resident after [MEDICAL TREATMENT] visits or coordination of care with the [MEDICAL TREATMENT] clinic. Resident #15 was 1 of 1 resident reviewed receiving [MEDICAL TREATMENT]. The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Hypertension, End Stage [MEDICAL CONDITION], Chronic Pain, Adult Failure to Thrive, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Debility, [MEDICAL CONDITION], and [MEDICAL CONDITION] with [MEDICAL CONDITION]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where s/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented " several attempts were made at an AV fistula, all failed and s/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related t… | 2014-06-01 |
| 10128 | 10128 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 250 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 14 residents reviewed for social services. Resident #16 failed to receive medically related social services for discharge planning and lost personal items. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. The resident was noted in the Resident Assessment Profile as being a short term rehabilitation resident, planning to return to home. The social service note dated 6/7/10 (admitted ) stated that the resident was living in an apartment alone at Pickens County disability prior to hospitalization and that" the goal is to d/c (discharge) home on 31st day. " Social service notes stated, "will visit on reg. 1:1 basis to observe moods and adjustment to placement." The social service notes contained 5 more entries -6/14/10, 6/21/10, 6/24/10, 7/6/10, and 8/3/10. None of the entries addressed discharge planning or assessment for the resident's plan to return home. There was no indication in the documentation that the social services director had talked with the resident regarding the plans to return home and no documentation that he/she had helped the resident with planning for the discharge to home. The information in the social services notes addressed areas,such as; the resident's mood, appetite, weight, and activities. There was no mention of the arrangements to prepare for a move back home, although the 31st day had passed on July 1, 2010. There was no documentation as to why the resident's discharge date had been extended. In review of the resident's current… | 2014-04-01 | ||
| 10129 | 10129 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 514 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews the facility failed to maintain accurately documented records for 3 of 18 records reviewed for accuracy of records. Resident #7 had inaccurate documentation related to the application of a sling, Resident #13 had inaccurate documentation related to the application of ted hose, and Resident #16 had inaccurate documentation of a Grievance/Complaint Report. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. He/she continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director (SSD) and the SSD was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. The Social Services Director in… | 2014-04-01 | ||
| 10130 | 10130 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 164 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies entitled "Competency Catheter Care- Female" (undated) and "Competency Catheter Care-Male" ([DATE]), the facility failed to provide adequate personal privacy for 2 of 2 sampled residents observed for catheter care. Appropriate clothing/draping was not provided for Residents #6 and #8 to prevent unnecessary exposure of body parts during catheter care. Also, based on random observation and interviews, the facility failed to provide privacy/confidentiality during medical/financial communication with Resident #13 in a common area of the facility. The findings included: The facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Prior to beginning catheter care on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 closed the corridor door and pulled the privacy curtain around the resident's bed. Observation revealed the resident lying in bed with a house dress pulled up to the epigastric area. A towel was positioned across the abdomen and perineal area. The resident's legs were bare to her/his ankles except for the disposable brief which was pulled down to the knees. Prior to the treatment, the CNA removed the towel drape and placed it below the resident's feet on the bed, exposing the resident from the epigastric area to the ankles. Resident #6 remained thusly exposed throughout the catheter care, perineal care, positioning on her/his left side, and cleansing of the buttocks and anal areas. The resident was then instructed to "lie back" which she/he did without assistance. Both staff then left the bedside with the resident exposed to wash their hands. They returned to the bedside and assisted the resident to replace the brief and pull down and snap the housedress in readiness to get out of bed. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 had not been draped appropriate… | 2014-04-01 | ||
| 10131 | 10131 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 241 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to promote care in a manner that maintained or enhanced dignity and respect. Staff failed to respect Resident #13's wishes to refuse to sign paperwork and terminate a conversation in a common area which resulted in increased agitation. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, "I'm not going to sign any papers!" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, "Don't touch me!" The staff member continued to ask her/him to sign the paperwork with the resident tearfully yelling out "No!" After the staff member left, Certified Nursing Assistant (CNA) #2 came and sat down next to the resident to talk to her/him. Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A CNA identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today she/he was not in a good mood. The OT stated that the resident would not sign the p… | 2014-04-01 | ||
| 10132 | 10132 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 157 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to notify the responsible party (RP) of changes. For one of five residents reviewed for falls, Resident #3 had a family member who was not notified of a fall with injury. The findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/23/10 at 1:45 PM revealed Resident #3 sitting on her/his bed. She/He had a dark swollen area on her/his forehead along with yellow/black discolorations under her/his eyes. Record Review on 8/24/10 at 11:52 AM revealed Nurse's Notes dated "8/11/10 5P(M) Resident asleep in high back chair + rolled onto floor. Has aprox(imately) 9 cm (centimeter) bruise to forehead. BP (Blood Pressure) 158/84, P(ulse)- 76, R(espirations)- 20, T(emperature)- 97.8. ROM (Range of Motion) (without) difficulty. Assisted to chair. Neuro (checks) WNL (within normal limits). No distress noted". "8/11/10 6 P(M) (Family member) called + notified of fall + injury." "8/11/10 6:15 P(M) Dr.__ notified on voice mail of fall + injury." Review of the Incident/Accident Report on 8/24/10 revealed the following: "Date of Incident/Accident: 8-11-10, Time of Incident/Accident: 5 PM, ...Name of Physician Notified: Dr. __, Date: 8/11/10, Time of Notification: 6:15 PM, Name and Relationship of Family Member/Resident Representative Notified: (Family Member), Date: 8/11/10, Time of Notification: 6 PM". During a phone interview on 8/25/10 at 9:00 AM, Resident #3's family member stated that she/he would be the person who would be notified if the resident's condition changed. The family member went on to state that she/he came in to visit her/his family member one afternoon and found bruises on Resident #3's face. She/He had asked the staff what had happened, but they didn't know. She/He stated that there was a big fuss made because nothing had been documented about it, but that she/he was told that Resident #3 had fallen the night before.… | 2014-04-01 | ||
| 10133 | 10133 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 309 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide care and services as ordered by the Physician for 2 of 18 sampled residents reviewed. The facility failed to ensure that Resident #13, on anticoagulant therapy, did not receive [MEDICATION NAME] after the Physician ordered the medication held due to an elevated PT/INR ([MEDICATION NAME]/International Normalization Ratio). In addition, Resident #13 did not have Ted Hose applied as ordered. Resident #7 did not have a sling applied as ordered by the physician. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 8/24/10 at 9:36 AM revealed a laboratory (lab) report dated 5/17/10. The PT was 37.2 H(igh). The reference range was listed as 9.4-10.8 sec(onds). The INR was 3.9 H(igh). The reference range was listed as .9-1.2 with the suggested therapeutic INR range for venous [MEDICAL CONDITION] and [MEDICAL CONDITION] listed as 2.0-3.0. A handwritten note to the right of the page stated "Dr. __: Hold [MEDICATION NAME]. Redraw PT/INR Thursday 5/20/10 and call to Dr. __during business hrs (hours) Thursday". Review of the Physician's Telephone Orders on 8/24/10 at 12:42 revealed an order to "Hold [MEDICATION NAME], Check PT/INR Thursday 5/20/10, Call results to Dr. __ during business hours Thursday". The Physician's Telephone Order had been dated 5/17/10 and the time next to "Signature of Nurse Receiving Order" was 6:45 PM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 5 mg (milligrams) (1) PO (By Mouth) (at) HS (Bedtime) 9P(M)". The [MEDICATION NAME] had been initialed as having been given on 5/15/10, 5/16/10, and 5/17/10. The [MEDICATION NAME] had been held from 5/18/10 through 5/22/10 and had been discontinued on 5/23/10 according to the MAR indicated [REDACTED] During an interview on 8/24/10 at 3:45 PM, the Director of … | 2014-04-01 | ||
| 10051 | 10051 | NHC HEALTH CARE, CHARLESTON | 425381 | 2230 ASHLEY CROSSING DRIVE | CHARLESTON | SC | 29414 | 2010-08-31 | 371 | E | 0 | 1 | SJ8211 | On the days of the survey, based on observation and interview, the facility failed to prepare food under sanitary conditions as evidenced by food service equipment and the floor with a build up of grease, dried food stains, and/or food debris on it. The findings included: Observations on 8/30/10 at approximately 6:15am revealed lids to the steam table had a build up of grease and food stains; drawers to the left of the sugar/flour bins had a build up of grease on the fronts and drawer pulls; a reach-in refrigerator to the right of the sugar/flour bins had dried spills on the front of the door; bakers racks at the end of the trayline had grease build up, dried spills, and food debris on the rails and uprights; a switch box at the prep sink had grease and dust on the top of the box; there was a wide strip of built up grime around the electric boxes on the floor under the prep and steam tables; and in the baking prep area there was a build up of grime at the juncture were the floor met the wall. Observations on 8/31/10 at approximately 10:55am with the Director of Food Service (DFS) confirmed that the above conditions were present. Interview at that time indicated that the kitchen had been pressure washed on 8/17/10 but had not cleaned closely around the electric boxes. S/he further indicated that there was a daily, weekly, and monthly cleaning schedule for the kitchen. Review of the daily cleaning schedule revealed "Baking Prep area, both tables top and bottom shelves, Dry bins, inside drawers, refrigerator inside and out, cart cleaned, all items dated and labeled. COOKS AREA ALL AREAS USED BY COOKS WILL BE CLEANED DAILY. . . " When surveyor asked to review the past week's completed daily cleaning schedule, the most recent completed schedule provided was 8/26/10. The DFS indicated that more recent completed schedules could not be found at that time. | 2014-07-01 |
| 10183 | 10183 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 279 | D | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop, review and revise the resident's comprehensive plan of care for 2 of 9 resident care plans reviewed. No Care Plan for Resident #7 was developed for [MEDICATION NAME] Therapy and Resident #9 had no Care Plan related to allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. On 9/7/2010 at 3:20 PM, review of the medical chart for Resident #9 revealed that the resident had multiple medication allergies [REDACTED]. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OPsite, *No sleeping Pills Per POA (Power Of Attorney). Further review indicated that there was no Care Plan in the record related to Resident #9's numerous allergies [REDACTED].#9 had no Care Plan for allergies [REDACTED]. The facility admitted Resident # 7 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 9/7/10 revealed this resident to be receiving [MEDICATION NAME] 5 mg(milligrams) every night. Lab studies were done per physician's orders [REDACTED]. Continued review revealed no care plan had been developed related to anticoagulant therapy and the [MEDICATION NAME] usage since the resident was admitted . In an interview with the DON (Director of Nursing) on 9/8/10, s/he confirmed there was no care plan related to the [MEDICATION NAME]… | 2014-04-01 | ||
| 10184 | 10184 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 281 | G | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews and review of the facility's protocol for Care Of Skin Abrasions, the facility failed to provide services for the residents which met the professional standards of quality for 1 of 9 residents sampled for professional standards and random observations during medication pass. Resident #9 had documented allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 9/7/2010 at 3:20 PM revealed that the resident had multiple allergy inconsistencies documented. The allergy sticker on the inside of the chart listed [MEDICATION NAME], Sulfa, [MEDICATION NAME], Amox. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OpSite, *No sleeping Pills Per POA (Power Of Attorney). Review of the Nurses' Notes dated 8/2/2010 at 0630 (6:30 AM), indicated that the resident had rubbed a scab off of the right side of her/his face. The nurse cleaned the area and applied "TAO (Triple Antibiotic Ointment) and a band-aid". At 5:00 PM, the Nurses' Notes revealed that the area on the right side of the resident's face was "red & (and) irritated. Res. (resident) states is painful to touch. On MD (physician) book for eval. (evaluation)." No other entries related to the resident's face were noted until 8/10/2010 at 4:40… | 2014-04-01 | ||
| 10185 | 10185 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 371 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Four of 4 ovens were observed to have dried, baked on spills on the interior walls, racks and floors of the ovens which extended to the exterior surfaces of the oven doors. The resident refrigerators on 2 of 3 units contained 16 [MEDICATION NAME] Extra nutritional supplements which had expired. The findings included: On 9/7/2010, during initial tour of the facility's kitchen, 4 ovens were observed to have a build up of food spills which were baked onto the oven doors and interiors. On 9/8/2010 at 8:40 AM, during an additional tour of the kitchen the ovens remained unchanged. On 8:45 AM, Dietary Staff worker #1 verified the ovens with the build up. At 9:20 AM, the Dietary Manager stated that the ovens were on a cleaning schedule but there was not a check of to ensure the staff had completed the task. A cleaning check off was initiated and provided on 9/8/10. During initial observation of the resident refrigerator on the Orchard View unit, 13- 8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010 were noted. The location of the supplements and expiration date was verified by the Director Of Nursing. At 10:35 AM, Licensed Practical Nurse (LPN) #1 stated that the unit had 1 resident receiving the [MEDICATION NAME]. The resident refrigerator on the Overlook Point Unit contained 3-8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010. The location of the supplements and expiration date was verified by Certified Nursing Assistant (CNA) #3. | 2014-04-01 | ||
| 10186 | 10186 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 492 | E | 9VMS11 | On the days of the survey, based on review of personnel files, the facility failed to verify 2 of 3 LPN's (Licensed Practical Nurses) license were in good standing with the State Board of Nursing prior to hiring. The facility also failed to verify the criminal back ground for 1 of 3 LPNs prior to the hire date.The findings included:On 9/7/10 review of LPN #7's personnel file revealed that LPN # 7 started work on 6/16/10, however the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 6/30/10. Review of LPN #8's personnel file revealed that LPN #8 started work on 7/7/10, the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 7/20/10. The facility also failed to complete a criminal background check for LPN #8 until 7/20/10. LPN #9's hire date was 7/7/10 and the facility completed the license verification on 7/20/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the nurses. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10187 | 10187 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 496 | E | 9VMS11 | On the days of the survey, based on employee personnel record reviews and interviews, the facility failed to verify certification checks and/or criminal background checks prior to beginning work for 3 of 2 Certified Nursing Assistant's reviewed for certification verification and criminal background checks.The findings included:On 9/7/10 review of employee personnel records revealed that the facility failed to verify certification for 2 of 2 CNAs (Certified Nursing Assistants) prior to beginning work. On 9/7/10, review of the CNA personnel records revealed:CNA # 1 began work on 6/9/10 with verification completed 8/11/10.CNA # 2 began work on 6/16/10 with her/his criminal background check completed on 6/17/10 and verification completed 7/31/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the CNA's. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10188 | 10188 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 160 | B | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds for conveyance upon death, the facility failed to convey one fund within 30 days of death, and failed to have proper authorization to convey 2 other resident funds. The findings included: An interview with the Business Office Manager on [DATE] related to conveyance of funds upon death revealed 3 of 4 accounts reviewed were refunded improperly. Account of Resident A, who expired on [DATE], was refunded by check written on [DATE]. The manager explained that corporate had recently found several accounts that had not been refunded, and she made out the check this day. Resident B had expired on [DATE] and a check had been made out to Colonial Trust on [DATE]. No legal authorization had been obtained to make the check out to this entity. Resident C expired on [DATE], and a check was made out on [DATE] to a son who had not been appointed as an administrator of the estate. | 2014-04-01 | ||
| 10189 | 10189 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 167 | C | 9VMS11 | On the days of the survey, based on observation and interview, the facility failed to post for resident review the Certification Survey for 8/20/09. The findings included: During a random observation on 9/7/10, the facility survey book, located upstairs in the skilled unit, was reviewed and found it contained last year's Licensure Survey, a Complaint Survey, and a Certification Survey dated 2008. The Certification Survey results for 8/20/09 were not included. The Director of Nursing (DON) reviewed the book and confirmed the survey was not included. The DON reviewed the survey book posted downstairs at the entrance and confirmed that book also did not have the 2009 Certification Survey included. | 2014-04-01 | ||
| 10190 | 10190 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 441 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of facility Infection Control Policies, Logs, and interviews, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection related to cleaning/non cleaning of glucometers, not making documented compliance rounds of all departments, and not keeping accurate infection control logs for trending and tracking of infections. There were also expired supplies in 2 of 3 medication rooms. The findings included: Review of the monthly infection control logs on [DATE] and [DATE] revealed list of x-rays done each month and pharmacy printouts for residents on antibiotics for each month with listings of residents, tests done, organisms identified, antibiotics started. However, these listings were not in order by date. When the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were interviewed regarding their infection control program, they stated the ADON filled out the log weekly or bi-weekly. They received the printouts from X-Rays and Pharmacy the next month so those were added to the logs then. The logs were not current. When asked how they did their tracking or trending for infections, they stated they had weekly meetings where infections were discussed. If they saw more infections were occurring, they would check to see which unit. No line listing of MDRO's ( Multi Drug Resistant Organisms) in the facility were being kept. The Admission's Coordinator would have to call someone in Nursing before placing a new resident. The ADON did not do compliance rounds to other departments for infection control. She stated she supposed the department heads did their own rounds. She did not receive any written reports for these. She did not do compliance rounds in nursing, but did competency checks on staff yearly. During observation of medication pass on [DATE] at 3:30PM, Licensed Practical Nurse #6 was observed to use a multi-residen… | 2014-04-01 | ||
| 10191 | 10191 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 309 | D | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to follow a physician's order to monitor Resident # 14's blood pressure before administering a medication. Resident #14 was one of four sampled resident's receiving medications with physician ordered parameters for administration. The findings included: Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. On 9/8/10, a review of the closed medical record revealed a physician's order for "[MEDICATION NAME] 60 milligrams, hold if pulse is less than 40" and notify the physician. A review of the July and August 2010 Medication Administration Records revealed there was no documentation that the resident's pulse was obtained/documented prior to the medication administration given daily at 6AM, 12P, 6P, or 12AM. The findings were verified and not disputed when shared with the Director of Nursing on 7/8/10 at 10:30 AM. | 2014-04-01 | ||
| 10269 | 10269 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 279 | D | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observations and interviews, the facility failed to develop and implement care plans with interventions to prevent aspiration for Residents #1, #2, #3 and #4 prescribed mechanically altered diets with nectar thick liquids and assessed as at risk for aspiration. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. Has severe dysphagia with high aspiration risk, family declines feeding tube." Interventions listed "will provided diet/snacks as ordered, will report hypo/hyper glycemia, will honor food preferences, will provide OHA's (oral hypoglycemic agents) as ordered". The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." Interventions included "will provide honey thick liquids as… | 2014-01-01 | ||
| 10270 | 10270 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 315 | G | 916711 | **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 appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hos… | 2014-01-01 | ||
| 10271 | 10271 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 281 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection..." On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/… | 2014-01-01 | ||
| 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 | ||
| 10194 | 10194 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 441 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to sanitize residents' personal laundry. The findings included: During observation on 9/14/10 at approximately 1:36 PM, Laundry Aid #1 loaded multiple residents' personal laundry into the washer and set the cleaning solution pump on "F1." The sign posted on the wall stated F1 solution was without bleach. During an interview at that time, the laundry aid stated she always used setting 1 for residents' personal clothes so they wouldn't be damaged. At 1:46 PM, during an interview, the Area Mechanic stated the water in the washer was between 115 and 120 degrees. He further stated the water used to be at 180 degrees but, after changing chemicals, they had been told the water temperature didn't need to be that high. At approximately 3:08 PM on 9/14/10, the Director of Environmental Services confirmed that the F1 setting did not include bleach and stated the (solution) pump should have been set on the F2 setting which added bleach after five minutes. Review of the detergent container did not reveal that the detergent contained any sanitizer. The Director of Environmental Services did not provide any additional information that the detergent had any bateriocidal properties. | 2014-03-01 | ||
| 10195 | 10195 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 333 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that one of 20 residents reviewed for medication assessment was free of significant medication errors. Potassium was not administered as ordered to Resident #6 for a period of 5 days. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was "nil" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed 7-19-10 physician's orders [REDACTED]. Review of the 7-19-10 Basic Metabolic Profile revealed the following results: Sodium = 130 LOW (reference 135-145 mmol/L); Potassium = 4.9 (reference 3.6-5.0 mmol/L); Chloride = 95 LOW (reference 101-111 mmol/L); Blood Urea Nitrogen = 52 HIGH (reference 6-20 mg/dl); Creatinine = 1.8 HIGH (reference 0.5-1.2 mg/dl). Review of the 7-10 Documentation Record (Medication Administration Record/MAR) revealed that the medication was held as ordered and that the [MEDICATION NAME] was resumed on 7-27-10. The Potassium (20 milliEquivalents daily) was not initialed on the MAR indicated [REDACTED]. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses verified that the medication had not been initialed as given for the five day period as noted. She stated she had been unaware of the omissions, no medication error report had been completed, and the physician had not been notified. She reviewed the record and verified that no recent Potassium level had been drawn. | 2014-03-01 | ||
| 10196 | 10196 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 315 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled "Skills Checklist for Suprapubic Catheter Care", the facility failed to ensure appropriate treatment and services for residents with catheters. The Certified Nursing Assistant (CNA) failed to properly anchor the suprapubic catheter tubing during catheter care for Resident #2, one of three residents observed with catheter care. Also, the facility failed to assess oral intake and urinary output as indicated by residents' medical condition for one of two sampled residents reviewed with an indwelling Foley catheter and Care Plan for intake and output monitoring. Resident #6, with a history of fluid imbalance and [MEDICAL CONDITION], had incomplete intake and output documentation. The findings included: The facility admitted Resident #2 on 10/22/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 9/14/10 at 12:23 PM revealed CNA(Certified Nursing Assistant) #2 cleaning, rinsing, and drying the catheter tubing. She held the tubing between her index finger and thumb, approximately 4 inches from the insertion site, and anchored it to the resident's thigh while wiping down the tubing. The CNA cleansed from the insertion site distally toward where she held the catheter, causing undo tension on the catheter tubing. During an interview on 9/15/10 at 11:25 AM, CNA #2 verified she had anchored the catheter tubing at the resident's thigh instead of at the insertion site while performing catheter care. She stated she thought she was supposed to anchor the tubing to the thigh. Review of the policy entitled "Skills Checklist for Suprapubic Catheter Care" on 9/15/10 revealed "...6. Apply soap to one wet cloth, 7. Hold tubing (Without pulling) in other hand, 8. Wash around one side of tubing with soapy cloth-, 9. Using a different, clean part of cloth- wash around the other side of the Tubing, 10. Hold the tubing closest… | 2014-03-01 | ||
| 10197 | 10197 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 332 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.5 %. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 9/13/10 at 8:36 PM, during observation of medication pass, Registered Nurse (RN) #5 was observed to administer two Klor-Con 10 (Potassium Chloride Extended Release) tablets and 7 other medications to Resident #10. During an interview on 9/13/10 at 8:48 PM, RN #5 revealed that supper trays arrived on the unit at about 6 PM and that Resident #10 had eaten in his room (approximately 2 and one-half hours before the potassium was administered). The Drug Facts and Comparisons book, page 49 (Potassium Replacement Products), states (under "Patient Information"): "May cause GI (gastro-intestinal) upset; take after meals or with food and with a full glass of water." Error #2: On 9/13/10 at 9 PM, during observation of medication pass, RN #2 was observed to administer one drop of [MEDICATION NAME] Ophthalmic Solution and one drop of [MEDICATION NAME] Ophthalmic Solution to the right eye of Resident A with one minute and 56 seconds between the two drops. RN #2 then administered one drop of the same two eye drops to the resident's left eye with 2 minutes and 4 seconds between the 2 drops. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Because of rapid lacrimal drainage and limited eye capacity, if multiple drop therapy is indicated, the best interval between drops is 5 minutes. This ensures that the first drop is not flushed away by the second or that the second drop is not diluted by the first.". Error #3: On 9/14/10 at 7:47 AM, during observation of medication pass, RN #1 was observed to instill one drop of [MEDICATION … | 2014-03-01 | ||
| 10198 | 10198 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 225 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property" dated 2/09, the facility failed to complete a thorough investigation for one of one reportable incidents reviewed for misappropriation of funds. The findings included: One of three reportable incidents reviewed on 9/15/10 revealed that a resident reported $44.00 missing from his room on 9/7/10. According to the DHEC (Department of Health and Environmental Control) Five-Day Follow-Up Report dated 9/13/10, "He had noticed this the week prior to the report". Under "Witnesses and other Staff on duty at time of/or prior to Reportable Incident:", there was nothing written. According to the report, the missing money had been reported by the facility to the Union County Sheriff's Office on 9/8/10. The "Summary Report of Facility Investigation:" stated "(Resident) keeps various items in the basket where he reported the money had been stored. (Numerous pieces of mail, straws, playing cards, and various other items). He has been reminded again to lock up any large amounts of money." Attached to the Five-Day Follow-Up Report was a letter dated May 4, 2010 from the Administrator addressed to residents and their families reminding them that the facility could store valuables and that residents are encouraged to not keep any items of personal or monetary value in their room. The letter went on to state that "The facility will take every precaution to protect belongings but cannot be accountable for valuables left in resident rooms". There were no resident or staff statements attached or evidence of a thorough investigation being completed. During an interview on 9/15/10 at approximately 12:30 PM, the Social Services Director (SSD) stated the resident had a history of [REDACTED]. After reviewing the Five-Day Follow-… | 2014-03-01 | ||
| 10199 | 10199 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 323 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, "DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : "RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness". SAFETY STATEMENTS on the MSDS read: "Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges." HANDLING AND STORAGE SECTIONS of the MSDS stated, "STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). K… | 2014-03-01 | ||
| 10200 | 10200 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 309 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to follow physician's orders for application of Knee High TED (antiembolism stockings) Hose for Resident # 11, 1 of 4 residents reviewed with orders for TED Hose. The facility also failed to include provision of Services from a Chaplain and Social Services in the care plan and no documentation of visits from these disciplines were found in the record for Resident #18, 1 of 2 resident's reviewed receiving Hospice Services . The findings included: The facility admitted Resident #11 on 4/26/04 with [DIAGNOSES REDACTED]. Record Review on 9/14/10 at approximately 6:15 PM revealed a Physician's Order for "Knee high TED hose on in the morning before getting out of bed & (and) remove at bedtime ([MEDICAL CONDITION])" with a start date of 9/16/08. Observation of the resident at 6:25 PM on 9/14/10 revealed the resident was not wearing TED Hose. During an interview on 9/15/10 at 1:15 PM, the resident stated she had never had any stockings and that she did have swelling in her feet "sometimes." Review of the resident's Minimal Data Set revealed the resident was coded as not having any short or long term memory problems. The resident was named on the list provided by the facility of Interviewable Residents and she was a member of the Resident Council. Record Review on 9/15/10 at approximately 1:30 PM revealed that the TED Hose had been signed off daily for August and September, including being signed off for being applied the morning of 9/15/10. During an interview on 9/15/10 at approximately 2:15 PM, Registered Nurse (RN) #4 stated she had just received a new pair of TED Hose for the resident the previous week. Upon observation of the resident, RN #4 confirmed the resident was not wearing TED Hose. RN #4 was unable to locate any TED Hose in the resident's drawers. When informed of the resident's statement that she had never had any stockings, RN #4 stated:… | 2014-03-01 | ||
| 10201 | 10201 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 322 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility's policies entitled "Gastrostomy Tube Check List" and "Procedure for Cleaning 60 cc (cubic centimeters) Syringes Used for Resident Feeding", the facility failed to utilize universal precautions and clean technique when flushing the Gastrostomy (G-) Tube and when cleaning and storing the piston syringes and gravity set for 2 of 3 residents observed for Gastrostomy Tube flushes. The findings included: The facility admitted Resident #5 on 7/17/09 with [DIAGNOSES REDACTED]. On 9/14/10 at approximately 12:33 PM, Licensed Practical Nurse (LPN) #6 was observed by two surveyors providing a Gastrostomy Tube flush before and after medication administration without washing her hands prior to initiating the procedure. LPN #6 opened the Medication cart, retrieved a bottle of liquid Tylenol from the drawer and poured 20 milliliters (ml) of Tylenol into a medication cup. LPN #6 proceeded to the resident's room, knocked, entered the room and filled the 2 empty medicine cups with 30 ml of water from the sink and placed all 3 medicine cups on the over-bed table. She then closed the door, opened a plastic bag and placed it on the foot of the bed and donned a pair of non-sterile gloves. LPN #6 proceeded to check for and replace residual, checked for placement of the [DEVICE], and administered the 30 ml flush, the medication and ended with another 30 ml flush. Upon completion of the procedure, the piston syringe was rinsed and placed wet, back into the bag. Review of the "Gastrostomy Tube Check List" provided by the facility on 9-14-10 revealed "2. Placement check: Check placement before flushes,...Gather supplies..., Explain procedure to Resident, Provide Privacy, Wash Hands, (apply) Non-sterile gloves, ..." The facility admitted Resident #3 on 4-8-01 with [DIAGNOSES REDACTED]. Prior to observation of a Gastrostomy (G-) feeding and flush on 9-14-10 beginning at 9:55 AM, two C… | 2014-03-01 | ||
| 10202 | 10202 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 328 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to follow the Physician's Orders for the administration of oxygen for 1 of 4 sampled residents reviewed with oxygen. Resident # 18 oxygen rate was observed above the stated physician's order. The findings included: The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of the record on 9/15/10 at approximately 11:00 AM revealed a Physician's order for O2 (oxygen) at 2 liter per minute (lpm) via NC (nasal cannula.) Review of the Hospice Nursing Visit Note revealed the Hospice nurse had documented the oxygen at 3 lpm via NC on 9/15/10, 9/8/10 and on 8/23/10. Review of the Documentation Record (MAR) revealed facility nursing staff was signing off the O2 at 2 lpm via NC each shift including the days of the survey. Observation on 9/15/10 at approximately 11:30 revealed the oxygen was flowing at approximately 3 1/2 lpm via NC. At approximately 1:00 PM on 9/15/10, Registered Nurse (RN) # 4, verified the oxygen was flowing at 3 1/2 lpm via NC. Upon questioning, she stated "I'd have to check the MAR (Documentation Record) but I'm pretty sure it's supposed to be at 2 (lpm)." RN #4 also reviewed the record and confirmed the Physician's Orders and the MAR indicated and could not locate any new order to increase the flow rate. During an interview on 9/15/10 at 2:28 PM, the Hospice Nurse stated the oxygen was supposed to be at 2 lpm and had been since admission to Hospice. She stated she thought the oxygen flow rate had inadvertently been changed on 9/15/10 when the Certified Nursing Assistant had reached to turn the oxygen back on after the resident's AM care had been completed. She stated the 3 lpm documented on the Nursing Visit Note for 9/15/10 had been a documentation error only. The Hospice Nurse later changed the documentation on the 9/8/10 Nursing Visit Not… | 2014-03-01 | ||
| 10203 | 10203 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 468 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to equip multiples areas in the corridors with handrails. The findings included: On 9/15/10 at approximately 1:55 PM, multiple areas leading into or on corridors were observed without handrails affixed to the walls. Areas included, but were not limited to: -an area approximately 3 1/2 feet at the entrance to Rocky Road Hall on the left and right sides of the hall -an area approximately 3 1/2 feet at the entrance to Rainbow Row Hall on the right side of the hall -approximately 5 feet across from the Unit I Nurses Station -a section approximately 8 feet long in a corridor behind the Unit I Nurses Station -the entire length of the corridor connecting Unit I and Unit II on both sides of the hallway -two 5 foot sections and two 3 1/2 foot sections on Unit II at the Nurses Station and several other areas leading into the 3 halls from the nurses station. During an interview on 9/14/10 at approximately 4:15 PM, the Maintenance Director verified multiple areas were without handrails and stated that the corridor between Units I and II had never had handrails as far as he knew. He also stated that the area behind the Unit I Nurses Station "looks like there used to be one there." | 2014-03-01 | ||
| 10272 | 10272 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 328 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record review the facility failed to ensure residents received timely foot care. The physician saw resident #2 and prescribed an antibiotic and cleaning to the right toenail bed until seen by the podiatrist related to redness of the toenail bed; resident #2 had a history of [REDACTED]. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to skin care. Review of the current medical record on 09/16/2010 revealed the most recent Podiatry visit as 01/20/2010. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during care the toenails came off on 03/14/2… | 2014-01-01 | ||
| 10273 | 10273 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 157 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review the facility failed to notify the physician of changes for one of five residents reviewed for foot care. Resident #2 with prescribed antibiotics for an infection of the left great toe developed "a purlent (sic) yellow discharge" that was not reported timely to the physician. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to foot care. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during foot care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010. | 2014-01-01 | ||
| 10297 | 10297 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 272 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents were comprehensively assessed related to a history of falls for 2 of 2 residents reviewed who had repeated falls (#1 and #3). Both residents had a history of [REDACTED]. The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation. She was discharged home on[DATE]. The admission nursing fall assessment showed a score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) notes revealed the resident was at risk for falls. "She is at risk for falls related to Hx (history of) falls and Dx ([DIAGNOSES REDACTED]. The note failed to provide any history of the resident's falls, and therefore there was no evaluation of any pattern or possible triggers for the falls. The RAP note did not evaluate the resident's internal or external risk factors. The resident fell three times while at the facility, 7/27/10, 7/28/10, and 8/22/10. One fall, the one on 7/28/10, resulted in a fractured distal right clavicle. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. However, the facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. There was no evidence of a comprehensive assessment of the resident's falls either on admission o… | 2014-01-01 | ||
| 10298 | 10298 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 280 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in … | 2014-01-01 | ||
| 10299 | 10299 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 323 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistan… | 2014-01-01 | ||
| 10300 | 10300 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 496 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of a Certified Nursing Assistant's employee file and interview, the facility failed to ensure that information was sought from every State registry before allowing an individual to serve as a nurse aide for 1 of 1 employee file reviewed. The findings included: The employee file of a Certified Nursing Assistant (CNA) who was assigned to a resident who fell and was later diagnosed with [REDACTED]. The facility checked the South Carolina CNA Registry for information prior to hire, but failed to check with the Massachusetts CNA Registry. The Assistant Director of Nurses confirmed this after she spoke with Human Resources personnel. | 2014-01-01 | ||
| 10283 | 10283 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 281 | D | OR4T11 | **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 clarify and follow a Physicians order related to discontinuing [MEDICATION NAME] for Resident # 12, 1 of 1 resident reviewed on anticoagulant therapy. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed a physician's orders [REDACTED].= 2.0". Further record review revealed an INR drawn on 9/13/10 was 4.05 and on 9/14/10 the INR was 3.03. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The INR results dated 9/9/10 had an order written [REDACTED].> 2). On 9/21/10 at 1:00 PM Licensed Practical Nurse (LPN) # 2 stated during an interview that "the order should have been clarified, because the orders are not the same. Someone should have called the doctor and asked about it, I think it should be stopped after it is greater than 2.0." The Unit Manager for the 100 hall stated during an interview on 9/21/10 at 2:00 PM " It (the [MEDICATION NAME]) should have been stopped when they got a INR of 2.0 or greater." During a telephone interview with LPN # 3 on 9/22/10 at 10:40 AM she confirmed that she took the order and stated " they were to stop the [MEDICATION NAME] when the INR is 2.0 or greater, I don't know why I would have written equal, that is just a slip of the pen or something, but it should be stopped when the INR is 2.0 or greater.". LPN # 2 called the Physician and received a clear order on 9/21/10 at 1:00 PM which reads "D/C [MEDICATION NAME] when INR greater than or equal to 2.0". | 2014-01-01 | ||
| 10284 | 10284 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 329 | E | OR4T11 | **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 decrease [MEDICATION NAME] as ordered for Resident # 12. The resident received 30 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Licensed Practical Nurse (LPN) # 2 stated during a interview on 9/21/10 that "the nurse who checked the MAR indicated [REDACTED]." The Unit Manager for Hall 100 stated during an interview on 9/21/10 " I checked those MAR's and I missed that, it is a problem." Both nurses stated " we will need to do a medication error report on this." | 2014-01-01 | ||
| 10285 | 10285 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 502 | D | OR4T11 | **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 laboratory services were provided in a timely manner for 1 of 13 residents (Resident #4) reviewed for laboratory services. The findings included: The facility admitted Resident # 4 on 6/18/10 with the following Diagnoses: [REDACTED]. The record review on 9/20/10 revealed an order for [REDACTED]. On the bottom of this report a note/recommendation was made that stated " Mixed culture: 3 or more organisms isolated suggest repeat culture to rule out contamination." No other reports were found on the medical record. During an interview with Licensed Practical Nurse # 2 she stated " we should get another urine sample". This resident does have a Foley catheter and a history of Urinary Tract Infections with the last one documented and treated in July 2010. | 2014-01-01 | ||
| 10274 | 10274 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 225 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to report an injury of unknown origin within the allowed time frame, failed to promptly begin an investigation into the injury, and failed to thoroughly investigate the resident's injury for a possible explanation of how it occurred for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower. Review of the Change Of Condition Nurses Notes and Resident Incident Report showed the discoloration was to the left back. There was no inflammation or [MEDICAL CONDITION] noted to the area. The facility did not report this injury of unknown origin or begin any investigation into the injury's possible origin. The facility did report to the State survey and certification agency on 7/15/10 that the resident's weekly skin audi… | 2014-01-01 | ||
| 10275 | 10275 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 496 | D | LLC411 | On the days of the survey, based on review of employee information provided, the facility failed to ensure that registry verification was completed before allowing an individual to serve as a Certified Nursing Assistant (CNA) for 2 of 3 employees reviewed who were hired in 2010 as CNAs. The findings included: During the complaint investigation, information concerning the staff on duty around the time of an injury of unknown origin was requested from the facility. The information provided failed to show that two of the CNAs had registry verification checks done prior to hire. The Director of Nurses (DON) was asked for this information on 9/28/10. On 9/29/10, the DON stated she knew the registry verification checks were done before hire, but Human Resources could not produce evidence of this. | 2014-01-01 | ||
| 10276 | 10276 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 514 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, the facility failed to ensure that resident records were complete and accurately documented for 1 of 3 resident records reviewed (#3). Documentation in the medical record concerning Resident #3's injury of unknown origin was incomplete and inaccurate. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Change Of Condition Nurses Notes showed staff found a discoloration on the resident's left back. The area was without inflammation or [MEDICAL CONDITION]. The nurse's note by LPN #1 did not describe the discoloration's size, shape, color, or specific location on the resident's left back. Certified Nursing Assistant (CNA) #3 found the area on 7/13/10 after the resident's shower and reported it to the nurse for assessment. This CNA was interviewed on 9/28/10 at 4:20 PM and stated what he saw was an area under the resident's left axilla extending to the left breast, it was blackish blue in color, and was approximately 4 by 4 centimeters big. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated; approximately 3 inches by 1 inch, reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. Documentation in the Change of Condition Nurses Notes on 7/14/10 by LPN #1 described the "left flank discoloration" as not as large as yesterday. The medical record showed no information of any discolored area on the resident's flank. LPN #1 did not reference the resident's left flank in either her interview or in her statement. The information at the top of the page on the 7/15/10 Change of Condition Nurses Notes showed the resident's bruise on the left back was not as large. Purple discoloration was noted on the upper anterior left arm and left chest. Farther down the page, under the Current Care Plan Interventions and physician's orde… | 2014-01-01 | ||
| 10277 | 10277 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 323 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower in the left axilla area. On 7/15/10, the resident's weekly skin audit on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: "Res. wa… | 2014-01-01 | ||
| 10292 | 10292 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 441 | F | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews and interviews, the facility failed to provide Tracheostomy care for one of one resident reviewed for tracheostomy care in a manner that would prevent possible infection on Resident #11. In addition the facility failed to track/trend infectious organisms and failed to adequately notify visitors of contact precautions. The findings included: The facility admitted Resident #11 on 5/12/10 with [DIAGNOSES REDACTED]. Review of the September 2010 cumulative physician's orders [REDACTED]. Observation on 9/28/10 at approximately 4:50 PM revealed Licensed Practical Nurse (LPN) #5 entered the resident's room. After assessing the resident, he put on a pair of clean gloves and suctioned inside and around the tip of the tracheostomy opening with a [MEDICATION NAME] suction catheter. He did not wash his hands prior to putting on the gloves. With the same gloved hands that he had used to suction with the [MEDICATION NAME] catheter, he opened a new inner cannula from a box container, removed the inner cannula from the resident's tracheostomy, and inserted the new inner cannula into the tracheostomy. With the same gloved hands, he then opened the drawer to the bedside table and removed a sterile suction kit. He put one sterile glove on his left hand without removing the other gloves and proceeded to perform endotracheal suctioning to the resident. During an interview on 9/29/10 at 5:13 PM, LPN #5 verified he put on gloves without washing his hands first, put on a sterile glove over a dirty one, and touched the drawer handle and supplies with the same gloved hands used for suctioning. He stated that the reason he put the sterile glove over the dirty one was that the sterile gloves were too small and ripped causing mucus to get on his hands. Review of the policy provided by the facility entitled "Suctioning of Tracheostomy" (dated 11/25/97) on 9/29/10 at 12:58 revealed under Procedure..."3. Assembl… | 2014-01-01 | ||
| 10293 | 10293 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 225 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the D… | 2014-01-01 | ||
| 10294 | 10294 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 280 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and update the Care Plans for 2 of 18 sampled residents reviewed for comprehensive Care Plans. Resident #13's Care Plan was not updated related to [MEDICAL CONDITION] and drug seeking behaviors; Resident #30's Care plan was not updated related to skin tears. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an interview on 9/30/10 at approximately 12:15 PM, Registered Nurse (RN) #2 stated Resident #13 had been exhibiting drug seeking behavior. According to the nurse, the resident told the physician on 9/20/10 that the [MEDICATION NAME] wasn't working any more and he subsequently discontinued it. Review of the physician's orders [REDACTED]. The nurse stated that the resident kept asking for the [MEDICATION NAME] again, so the nursing staff had to call the on-call physician that same night who gave an order for [REDACTED]. MD (physician) will evaluate in AM". When asked what was being done to address this issue, the nurse stated the resident had been seen by Psychiatry and had a trial of [MEDICATION NAME]. Review of the "Psych Consult and Progress Notes" dated 3/10/10 revealed that Resident #13 had been diagnosed with [REDACTED]. According to the note "Case discussed with staff. Pt. (Patient) had been refusing q (every) hs (Bedtime) [MEDICATION NAME] (Secondary) to "SE" (Side Effects) Upset stomach, [MEDICAL CONDITION] of feet which attributed to (increased) dose. Pt. would like to try another medicine & asks for [MEDICATION NAME]. I explain(ed) to her that this will not help (with) depression & Pt. is already taking [MEDICATION NAME] which is similar. Pt denies SI (Suicidal ideation). She has been cooperating with care. (No) voiced [MEDICAL CONDITION]. Pt is oriented x3. Meds (Medications) [MEDICATION NAME] 1 mg (milligram) PO (By Mouth) Q (every) AM. [MEDICATION NAME] 60 mg PO Q AM, [MEDICATION NA… | 2014-01-01 | ||
| 10243 | 10243 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2010-10-12 | 225 | E | 8JQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record review, interview, and review of the facility's reportable file since 4/9/10, the facility failed to report to the State survey and certification agency 4 of 8 allegations of misappropriation of resident property (Residents A, B, C, D), failed to report timely 3 of 4 allegations of misappropriation (Residents #1, E, F), and failed to thoroughly investigate 4 of 8 allegations of misappropriation (Residents A, B, C, and D). The findings included: Resident #1 reported to the facility on [DATE] that her wallet was missing. The Complaint/Grievance Report stated the resident reported that approximately $30.00 was in the wallet. The facility's initial 24 hour report also noted the resident's debit card was taken and that there had been some activity on the resident's debit card account. The initial report to the State survey and certification agency was dated 9/28/10, which exceeded the 24 hour deadline for reporting allegations of misappropriation. Review of the facility's grievance files revealed three addition allegations of misappropriation around the same time Resident #1 made her complaint. Resident A reported $4.00 missing on 9/24/10. Resident B reported $14.00 missing on 9/27/10. Resident C reported $9.00 missing on 9/28/10. Residents B and C had notations on their grievance stating "resolved by personnel action (secondary to) cluster of similar events on Unit 200." None of these allegations was reported to the State survey and certification agency or thoroughly investigated. Continued review of the facility reportable incidents revealed another cluster of allegations concerning misappropriation of resident property in April 2010. Resident E reported on 4/10/10 that $63.00 was missing. The resident's allegation was not reported until 4/12/10. Resident F reported on 4/16/10 that $20.00 was missing. The allegation was reported to State agency on 4/20/10. Resident D reported "missing $" on 4/16/… | 2014-02-01 | ||
| 10254 | 10254 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 157 | G | GYKK11 | **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 consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. N… | 2014-02-01 | ||
| 10255 | 10255 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 281 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Wil… | 2014-02-01 | ||
| 10256 | 10256 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 312 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, "scratches won't leave band aid on." On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing. | 2014-02-01 | ||
| 10257 | 10257 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 280 | D | GYKK11 | **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 revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she "slid" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-10 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed "Resident found sitting on floor in front of chair". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed "Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse". There were no additional commen… | 2014-02-01 | ||
| 10258 | 10258 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 272 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the … | 2014-02-01 | ||
| 10259 | 10259 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 225 | E | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-2010 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room … | 2014-02-01 | ||
| 10260 | 10260 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 253 | D | GYKK11 | On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained. | 2014-02-01 | ||
| 10261 | 10261 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 323 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers… | 2014-02-01 | ||
| 9584 | 9584 | KINGSTREE NURSING FACILITY | 425117 | 401 NELSON BOULEVARD | KINGSTREE | SC | 29556 | 2010-10-13 | 156 | B | 0 | 1 | M1ZN11 | On the days of the survey, based on record review and interview, the facility failed to provide documentation of the timely notification of Medicare Provider Non-Coverage (CMS Form ) for 1 of 3 residents reviewed (Resident A). In addition, the facility failed to provide the required Liability Notice to 2 of 3 residents reviewed (Resident A and Resident #4). The findings included: Review of Notices of Medicare Non-Coverage for Resident A on 10/12/10 revealed the Centers for Medicare and Medicaid Services (CMS) Form indicated that current Skilled Services would end on 8/26/10. Review of the form revealed no resident or representative (RP) signature and no documentation to indicate when/how the resident or RP was notified of this change. In addition, CMS dated 8/16/10 was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. Review of Resident #4's Notice of Medicare Non-Coverage revealed CMS was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. During an interview on 10/13/10 at approximately 10:30 AM, a member of the facility's business staff reviewed the forms for Resident A and Resident #4 and confirmed the above findings. | 2015-03-01 |
| 9585 | 9585 | KINGSTREE NURSING FACILITY | 425117 | 401 NELSON BOULEVARD | KINGSTREE | SC | 29556 | 2010-10-13 | 502 | D | 0 | 1 | M1ZN11 | **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 laboratory test results were available for clinical management in a timely manner for 1 of 2 residents receiving [MEDICATION NAME] (Resident #2). The findings included: The facility admitted Resident #2 on 7/11/07 with [DIAGNOSES REDACTED]. Review of the medical record on 10/11/10 revealed Resident #2 received [MEDICATION NAME] 125 mg/5cc (miligrams/cubic centimeters) every 8 hours. Further record review indicated the current cumulative physician's orders [REDACTED]. LPN #1 was asked to review the laboratory results section of the medical record and confirmed that the May 2010 [MEDICATION NAME] Level was not on the record. When asked about the procedure for tracking when labs are due, LPN #1 stated that the Unit Manager posts a list of due/draw dates at each unit. During an interview on 10/13/10 at approximately 11:00 AM, RN #1 stated that the Unit Manager maintains a log for each resident that indicates when labs are due. RN #1 stated that lab results are faxed to the facility, sorted by the Unit Managers, and filed in the medical records after the physician signs the test results. RN #1 stated that when lab results are received, he/she documents the log with the date the lab was drawn. Review of the laboratory log for Resident #1 revealed the space to document the May 2010 [MEDICATION NAME] Level was blank. | 2015-03-01 |
| 9764 | 9764 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 323 | E | 0 | 1 | G9M911 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment was free of accident hazards. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with linoleum that was in disrepair: Room 13 - Linoleum was observed with adhesive not holding along the seam. The seam was uneven with elevated areas noted on both sides of the seam. Room 14 - Linoleum seam buckled in the middle with elevated areas on both sides of the seam Room 17 - Linoleum seam uneven and elevated in 2 areas (about 8 inches each in length) Room 22,- Linoleum seam on the right side of the room near Bed B was observed with adhesive not holding, resulting in elevated areas. Room 5 - Linoleum seam by bed C was observed with the adhesive not holding resulting in elevated areas along the seam. When a chair was slid across the seam of the linoleum, the leg of the chair caught on the seam. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director stated that he would re-glue the elevated areas of the linoleum and fill in any gaps along the seams with putty or other filler material, allow that to dry and then buff or sand down any uneven areas. | 2014-12-01 |
| 9765 | 9765 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 332 | E | 0 | 1 | G9M911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interview and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication errors rates of 5% or greater. The medication error rate was 8.7%. There were 4 errors out of 46 opportunities for error. The findings included: Error #1: On 10/11/10 at 4:25 PM, during observation of medication pass. Licensed Practical Nurse (LPN) #1 was observed to administer one [MEDICATION NAME] 500 milligram (mg) tablet and 4 other medications to Resident A, followed with water. Review of the current physician's orders [REDACTED]. Resident A's meal tray arrived at 5:54 PM. Error #2: On 10/12/10 at 8:10 AM, during observation of medication pass, LPN #2 was observed to administer two puffs of [MEDICATION NAME] Aerosol Inhalation to Resident B. LPN #2 handed the [MEDICATION NAME] Inhaler to the resident without instructing the resident to wait one minute between inhalations. Resident B self administered 2 inhalations with no wait between puffs. The Drug Facts and Comparisons book (updated monthly), page 669b, states (in reference to administration technique for aerosol inhalers): "Allow greater than or equal to 1 minute between inhalations (puffs).". Error #3: On 10/12/10 at 8:40 AM, during observation of medication pass, LPN #3 was observed to administer 1 puff of [MEDICATION NAME] HFA 110 to Resident C without shaking the canister before administration. The Drug Facts and Comparisons book (updated monthly), page 672a, states (in reference to preparation for administration of [MEDICATION NAME] HFA): "Shake well before using.". Error #4: On 10/12/10 at 8:42 AM, during observation of medication pass, LPN #3 was observed to administer one drop of Omnipred Ophthalmic Suspension to the right eye of Resident C without shaking the bottle before administration. The Drug Facts and Comparisons book (updated monthly), page 1725 states (under General Consider… | 2014-12-01 |
| 9766 | 9766 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 460 | E | 0 | 1 | G9M911 | On the days of the survey, based on observations and interview, the facility failed to provide ceiling suspended curtains, which extended around the bed to provide total visual privacy for each resident. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with curtains that did not extend around the bed to provide total visual privacy. -Room 23, curtain at foot of the bed was too short leaving an open gap -Room 9, bed D with front curtain about one foot too short -Room 12, bed A with front curtain about 8 to 10 inches too short -Room 13, bed C with side curtain too short -Room 19, bed B with curtain at foot of the bed which was hindered from covering the foot of the bed by the sprinkler pipe which was also suspended from the ceiling and touching the metal pipe holding the suspended curtain. The clips holding the curtain could not pass between the 2 pipes. -Room 22 bed A with front curtain which was about 2 feet short -Room 23 bed C with curtain at the foot of the bed too short. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director revealed that the short curtains had been replaced with longer curtains or additional curtains had been added in the affected rooms and that the sprinkler pipe in room 19 at the foot of bed B had been raised enough to allow the curtain to move along the pipe without being hindered. | 2014-12-01 |
| 9767 | 9767 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 425 | D | 0 | 1 | G9M911 | On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired medications and expired resident care products were removed from storage with other medications and resident care products, available for resident use, in 1 of 2 medication rooms. The findings included: On 10/12/10 at 2:53 PM, observation of the Back Hall Medication Room revealed the following: -two 5 Gram packets of Fougera Vitamin A + Vitamin D Ointment, expired 8/10 -three packs PDI Antiseptic/Germicide Swabsticks (3's), expired 3/10 -one Kendall Kangaroo All Silicone Gastrostomy Tube with Y-Port, expired 9/10 During an interview on 10/12/10 at 3:38 PM, Licensed Practical Nurse (LPN) #4 revealed that the Medication Nurses check the medication room for expired insulin and check the emergency drug kits. Pharmacy comes once a month to check medications. LPN #4 did not know who was responsible for checking supplies and stated that she did not know why Vitamin A and D Ointment and Antiseptic Germicide Swabsticks were in the medication room. | 2014-12-01 |
| 9768 | 9768 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 159 | F | 0 | 1 | G9M911 | On the days of the survey based on record reviews and interviews, the facility failed to hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. Two (2) of 5 resident trust accounts did not have proper authorization to manage the resident funds, 5 of 5 resident trust accounts were not managed according to accepted accounting principles and the facility failed to provide accurate accounting practices with the petty cash fund. The findings included: On 10/13/10 at 10:15 AM a review of 5 random Resident Trust Fund accounts and an interview with the Business Office Manager was conducted. The sample consisted of Residents # 3, #11, #14, and Resident D and E. Residents #3 and Resident D did not have an authorization in the records to allow the facility to manage their funds. The only authorization found in Resident #3 and Resident D's records related to The Resident Fund Management Service direct depositing the residents' Social Security check and the forms were signed by the Business Office Manager. There was no resident or Responsible Party signature on the form which did not constitute authorization to manage the residents' funds. During an interview with the current Business Office Manager on 10/13/10 at 10:15 AM, she informed the surveyor that they had changed their accounting system last Spring and now had a contract with Resident Fund Management Service in Virginia. It was her understanding that she or the previous Business Office Manager could sign the Resident Fund Management Service Authorization and Agreement to handle Resident Funds and that the resident or responsible party did not need to sign the form. Upon further review of the selected Resident Trust Fund sample on 10/13/10 at 2:30 PM it was revealed that Resident D had disbursements from his account for multiple Beauty/Barber services: 5/25/10-$13.00, 6/17/10-$10.00, 7/13/10-$10.00, 8/12/10-$10.00, and 9/28/10-$10.00. There were no resident signatures or witness signatures found in the file for the ser… | 2014-12-01 |
| 9769 | 9769 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 318 | E | 0 | 1 | G9M911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to provide appropriate intervention for identified contractures for one of three sampled residents reviewed with contractures. The facility failed to provide intervention to improve or maintain Resident # 6's range of motion in his upper extremities and failed to adequately assess if the resident had a decline in range of motion. The findings included: The facility admitted Resident # 6 on 4/8/04 with a [DIAGNOSES REDACTED]. On 10/10/10 at approximately 11:00 AM, during initial tour of the facility, Resident # 6 was observed with contractures of the right arm and hand and bilateral contractures of legs and feet. On 10/10/10 review of the resident's clinical record revealed on the MDSs (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 7/8/10, 9/22/10 and 10/5/10, that the facility had coded the resident as having the following limits related to range of motion: arm: one sided limitation with full loss of voluntary movement hand: one sided limitation with full loss of voluntary movement leg: limitation of both sides with full loss of voluntary movement foot: limitation of both sides with full loss of voluntary movement Review of the RAPS (Resident Assessment Protocol) dated 10/5/10 revealed that the resident had right sided [MEDICAL CONDITION] which was the resident's dominate side. Further review of the document on the ADL (Activities of Daily Living) Supplement, revealed that the facility stated that the resident was dependent except for feeding. Review of the Physician's cumulative orders dated 10/1/10 revealed a physician's orders [REDACTED]. Interview with the facility Rehabilitation Manager on 10/13/10 at 10:16 AM, revealed that the facility practice was to inform the nurses on the unit what services should be provided and that the Restorative CNAs are shown what should be done prior to beginning Restorative se… | 2014-12-01 |
| 9770 | 9770 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 278 | D | 0 | 1 | G9M911 | **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 ensure the accuracy of assessments on two of ten sampled residents reviewed for accuracy of assessment. The facility failed to accurately assess Resident # 7 related to wandering behaviors. In addition, the facility failed to accurately reflect Resident # 6's combativeness during care on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening. The findings included: The facility admitted Resident # 7 on 8/18/10 with diagnoses of [MEDICAL CONDITION]. On 10/10/10 review of the resident's clinical record revealed documentation on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 8/27/10 that the resident was coded as alert and oriented. In addition, the facility coded that the resident had not displayed any wandering behaviors. Review of the admission resident profile dated 8/18/10 revealed that the nurse had documented under the section for elopement risk, that the resident was not ambulatory, not resistant to being placed in a long-term care facility and had no history of elopement. The nurse documented that the resident displayed no indications or [DIAGNOSES REDACTED]. Review of the "Elopement Assessment Risk Tool" revealed that the resident had been assessed as a "5". Per the form, a score of 0-6 indicated being at low risk for elopement, 7-13 was considered moderate risk and 14 and above was considered a high risk for potential elopement and would warrant the need for extra supervision. No interventions were documented as needed to decrease the risk. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of the admission assessment completed by the Nurse Practitioner dated 8/18/10 revealed that she had documented that the resident was alert and oriented. Further review of the physician progress notes [REDACTED]. Review of the Nurses' notes dated 8/18/10… | 2014-12-01 |
| 10262 | 10262 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 280 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 4 sampled residents reviewed for Comprehensive Care Plans. Resident #1's Care Plan had not been updated regarding approaches used for proper positioning and to prevent and/or care for Pressure Ulcers. The findings included: The facility admitted Resident #1 on 09/06/2002 and readmitted her on 12/10/2004 with [DIAGNOSES REDACTED]. Observation on 10/18/2010 at 12:35 PM revealed the resident lying on a specialty mattress with the head of bed elevated. Review of the cumulative Physician order [REDACTED]. Review of the Physician/Nurse Practitioner Progress Notes on 10/18/2010 at 1:15 PM revealed the following: 06/16/2010- "S(ubjective): Resident had an area of skin compromise noted to her sacrum. Initial treatment was the use of [MEDICATION NAME] although wound treatment nurse reports the skin was intact at that time. However, we were called to see the resident today due to changes in the sacral wound...P(lan): ...Also, initiate a specialty mattress surface for the resident to minimize skin breakdown and to offload this area". 07/12/2010- "Patient is an elderly white female with a known history of advanced dementia, ... and essentially total care for activities of daily living (ADLs) and instrumental activities of daily living (IADLs)...". 07/14/2010- "Chief Complaint: Pressure Area. S(ubjective): Resident is frail and debilitated, cachectic, with wound on her sacrum...O(bjective): The wound is open...Heels are intact... P(lan): ...Keep resident turned and positioned...". 07/28/2010- "P(lan): She is on double shot protein q.i.d. (4 Times daily)...Heels are intact...Encourage turning and repositioning". 08/09/2010- "P(lan): ...Keep resident turned and repositioned". 08/30/2010- "P(lan):...Encourage turning and repositioning, although due to her frailty and debility would contribute greatly to poor wound healing.… | 2014-02-01 | ||
| 10263 | 10263 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 157 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to notify the physician with changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (… | 2014-02-01 | ||
| 10264 | 10264 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 514 | E | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 veri… | 2014-02-01 | ||
| 10265 | 10265 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 314 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to assess and address with the physician changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Pr… | 2014-02-01 | ||
| 10244 | 10244 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-10-19 | 225 | D | YPDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews the facility failed to ensure that all allegations of abuse/neglect were thoroughly investigate to prevent further abuse to residents #1 and #5. There was no documentation that the facility interviewed all staff on duty at the time of the incident (2 of 5 sample residents reviewed) The findings included: The facility admitted Resident #1 on 06/25/2010 and readmitted the resident on 07/30/2010 with [DIAGNOSES REDACTED]. Review of the facility investigation regarding a facility reported incident involving Resident #1 on 07/23/2010 revealed a statement written by Licensed Practical Nurse #1 that stated, "...I asked her when it started hurting she said yesterday at white guy help me from my bed to my chair he was in white uniform - he was with other workers. He picked me up under my arms and lifted me to the w/c (wheelchair) - felt a little pain not much..." The witness statement indicated the resident informed the facility staff that "he was with other workers". A review of the facility investigation revealed no interviews were done with the staff working at the time of the incident. The Social Services Director (SSD) stated that the facility did not have statements from staff on the unit at the time of the incident with Resident #1. The facility admitted Resident #5 on 12/20/2005 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 06/17/2010 that indicated the resident had memory problems but had no cognitive problems with daily decision making. Review of the facility grievance log revealed Resident #5 informed the facility on 08/05/2010 that a nurse, in the presence of three CNAs (certified nurse aides), grabbed her wrist and told her to move. There was no documentation the facility investigated the allegation and reported to the State Survey Agency. In an interview on 10/19/2010 at approximately 11:30 PM the DON (Director of Nursing) and… | 2014-02-01 | ||
| 9874 | 9874 | HERITAGE HEALTHCARE CENTER AT THE PINES | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2010-10-20 | 315 | D | 0 | 1 | TQ5V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review and review of the facility's policy for Catheter Care, one of two resident's observed for catheter care received inappropriate care during the treatment. The Certified Nurses' Assistant CNA anchored the catheter tubing distally and cleansed the tubing moving from the distal portion back to the proximal end of the tubing. The findings included: The facility admitted Resident # 19 on 06/17/2008 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident received [MEDICATION NAME] 50 milligrams at bedtime as a maintenance dose of antibiotic for urinary tract infections. During the catheter care treatment on 10/20/2010 at 9:45 AM, CNA #1 held the catheter tubing distally from the urinary meatus and with a disposable wipe cleansed the tubing as she moved the wipe up the tubing to the proximal end of the tubing at the opening of the meatus. In an interview with CNA #1, she confirmed that she did hold the tubing distally and that she did move the wipe towards the meatus instead of away from the meatus opening. Review of the facility's Catheters: Care and Anchoring, Changing of policy revealed in item 11.) ....cleanse catheter from insertion site to four (4) inches; outward. | 2014-10-01 |
| 9875 | 9875 | HERITAGE HEALTHCARE CENTER AT THE PINES | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2010-10-20 | 456 | E | 0 | 1 | TQ5V11 | On the days of the survey, based on observation, record review, policy review, and interview, the facility failed to maintain 1 of 2 unit refrigerators in safe operating condition. The North nutrition refrigerator maintained an inside temperature higher than the recommended acceptable parameters. The findings included: Observation of the North Unit nutrition refrigerator on 10/20/10 at 2:15 PM, revealed contents of Med Pass, soft drinks, and applesauce. The inside refrigerator temperature was 56 degrees. The Dietary Manager and Maintenance Director confirmed that the temperature was above the recommended parameters. Review of the refrigerator log for October 2010 revealed temperatures ranging from 42 - 62 degrees. Review of the facility policy titled "Refrigerator Temperatures" revealed that temperatures should be maintained at or below 40 degrees. During an interview with the Director of Nursing on 10/20/10, she stated that the night nurse was responsible for checking and documenting the temperature and should have reported that the temperatures were out of the acceptable range. | 2014-10-01 |
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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 );