cms_SC
Data source: Big Local News · About: big-local-datasette
10,300 rows sorted by inspection_text
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7880 | 7880 | POINSETT REHABILITATION AND HEALTHCARE CENTER, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2013-10-02 | 157 | D | 1 | 0 | 4KB411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician of an elevated blood sugar for one of one residents with a blood sugar of 500. Resident #1 had a blood sugar over 500 and the physician was not notified. The findings are as follows: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the resident's Physician Cumulative Orders revealed an order for [REDACTED].>(greater than) 500 give 12 units of Insulin SQ (subcutaneous) and call (the doctor). Review of the Diabetes Monitoring Record revealed on 8/7/13 at 7:00 AM, the resident's blood sugar was 529. The resident was given the 12 units of insulin but the doctor was not notified. On 10/2/13 at approximately 1:45 PM the Director of Nursing (DON) was interviewed by the surveyor. The resident's blood sugars were reviewed with the Director of Nursing. After reviewing the medical record, the DON confirmed the physician had not been notified of the 529 blood sugar. | 2016-10-01 |
| 4303 | 4303 | PRUITTHEALTH-CONWAY AT CONWAY MEDICAL CENTER | 425173 | 2379 CYPRESS CIRCLE | CONWAY | SC | 29526 | 2016-06-23 | 329 | D | 0 | 1 | 55GR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** : Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administration of an anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications.(Resident #130) The findings included: The facility admitted Resident #130 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. Further review of the Medication Administration Records(MAR's) for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #130 received [MEDICATION NAME] without documentation of attempting a non-pharmacological intervention as follows: 4/26/16-x 2, 4/27/16 x 2, 4/28/16 x 2 and 4/29/16; 5/2/16, 5/6/16, 5/8/16, 5/12/16, 5/13/16, 5/14/16, 5/15/16, 5/17/16 x 2, 5/20/16 x 2, 5/22/16, 5/23/16, 5/24/16 x 2, 5/25/16, 5/26/16 x 2, 5/27/16, 5/28/16 x 2, 5/29/16 and 5/31/16; 6/2/16 x 2, 6/3/16 x 2, 6/5/16, 6/7/16 x 2, 6/9/16, 6/10/16, 6/11/16 x 2, 6/12/16 x 2, 6/13/16 x 2, 6/14/16 x 2 6/15/16, 6/16/16 x 2, 6/18/16, 6/20/16 x 2, 6/21/16 x2, 6/22/16 x 2. Review of the nurse's notes for the dates listed above for the [MEDICATION NAME] administration revealed no documentation related to implementation of a non-pharmacological intervention prior to the [MEDICATION NAME] administration. During an interview on 6/23/16 at 4:38 PM with the Director of Nursing, after reviewing the resident's nurse's notes, he/she confirmed non-pharmacological interventions were sporadic and he/she would expect nurses to attempt a non-pharmacological intervention prior to the administration of an anti-anxiety medication. He/she stated there was no facility policy related to attempting a non-pharmacological intervention prior to administration of an as needed anti-anxiety medication. | 2020-04-01 |
| 2856 | 2856 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2019-08-09 | 600 | G | 1 | 1 | 0SKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 01/07/2020 Based on record review and interview, the facility failed to prevent verbal abuse and neglect of Resident #27, 1 of 8 residents reviewed for abuse and/or neglect. Resident #27 made an allegation of verbal abuse and neglect from CNA (Certified Nursing Assistant) #1. Resident #27 waited 4 hours and 15 minutes for care, when the CNA finally responded to the resident a verbal altercation ensued and LPN (Licensed Practical Nurse) #4 asked CNA #1 to leave the room. The facility report indicated the facility substantiated neglect. Review of Resident #27's Social Service Progress Notes revealed the Resident stated that (s/he) is still shook up about it and that (s/he) is fearful that the CNA will try to harm (her/him). (S/he) stated that (s/he) stayed up all night worried that the CNA would come into (her/his) room and harm (her/him) or try to shoot (her/him) through (her/his) window. The findings included: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #27's medical record revealed the Annual MDS (Minimum Data Set) dated 2/25/19 and the Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact for daily decision-making. On 08/08/19, review of the Initial 2/24-Hour Report dated 5/26/19 revealed Resident #27 made an allegation of verbal abuse and neglect from CNA #1. The facility's report indicated the incident occurred on 5/26/19 at 3:05 PM. Review of the Social Service Progress Notes revealed a note dated and timed 5/31/2019 at 08:50 AM Social Services followed up with resident about the incident on Sunday 5/26 with the CN[NAME] Resident stated that (s/he) is still shook up about it and that (s/he) is fearful that the CNA will try to harm (her/him). (S/he) stated that (s/he) stayed up all night worried that the CNA would come into (her/his) room and harm (her/him) or try to shoot (her/him) through… | 2020-09-01 |
| 2857 | 2857 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2019-08-09 | 607 | G | 1 | 1 | 0SKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 01/07/2020 Based on review of facility files, interview and the facility policy tilted Reporting Abuse to State Agencies and Other Entities, the facility failed to implement written policies and procedures related to reporting an allegation of abuse for Resident #346, 1 of 8 residents reviewed for abuse. The findings included: The facility admitted Resident #346 on 05/24/19 with [DIAGNOSES REDACTED]. On 08/06/19 at 03:24 PM, review of the Initial 2/24-Hour Report revealed the facility was notified of Resident #346's spouse's allegation of neglect at 1430 (02:30 PM) on 05/25/19. Further review revealed the facility alleged the report was submitted to the State Agency on 05/25/19 but there was no confirmation that the facsimile was sent to the Agency. Review of the report received by the state agency revealed it was received on 05/25/19 at 05:19 PM and not within the required 2 hour reporting time frame. During an interview on 08/06/19 at 05:15 PM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency and that the policy was not followed related to reporting. Review of the facility policy tilted Reporting Abuse to State Agencies and Other Entities revealed under Policy Statement All suspected violation and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Under Policy Interpretation and Implementation Should a suspected violation or substantiated incident of neglect violation or substantiated incident of neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; . Further review revealed Verbal/written notices t… | 2020-09-01 |
| 3393 | 3393 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2019-08-01 | 600 | G | 1 | 1 | V3M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 2/7/2020 Based on review of facility files and interview, the facility failed to ensure residents were free from abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy. | 2020-09-01 |
| 3394 | 3394 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2019-08-01 | 607 | G | 1 | 1 | V3M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 2/7/2020 Based on review of facility files, interview, and review of the facility's Abuse/Neglect Prevention Protocol, the facility failed to implement policies and procedures that prohibit and prevent abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy and this was not reported this timely. | 2020-09-01 |
| 954 | 954 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 658 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on observations, record reviews and interviews the facility failed to assure that care and services were provided according to accepted standards of clinical practice for 1 of 5 residents reviewed for unnecessary medications. Resident #12 had two different physician orders [REDACTED]. An interview with the Director of Nursing (DON) revealed that the nursing staff providing care to Resident #12 failed to realize there were two different orders in place for finger stick blood sugar testing resulting in additional finger sticks. An interview with Licenses Practical Nurse (LPN) #3 revealed that s/he was aware that the orders were confusing but failed to report this to the DON. The findings included: Resident #12 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/08/20, at approximately 3:47 PM, a random medical record observation revealed that Resident #12 had two different physician orders [REDACTED]. On 1/8/20 at approximately 4:04 PM, LPN #3 stated that the orders were confusing and that he/she had been intending to report this to the DON (Director of Nursing) but had not done so. On 1/8/20 at approximately 4:37 PM, the Surveyor made the DON aware of the finger stick blood sugar testing concerns related to Resident #12. On 1/8/10 at approximately 5:20 PM, a review of physician's orders [REDACTED]. The first was an opened ended physician order [REDACTED]. Blood Sugar is less than [AGE], Call MD. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, Give 6 Units. If Blood Sugar is 301 to 350, Give 8 Units. If blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Three times a Day; 07:30 AM, 11:30 PM, 05:30 PM. After reviewing Resident #12's medical record it revealed that Resident #12 was being tested ,[DATE] times daily for blood sugar levels. On 1/8/20 at approximately 5:40 PM, the DON stat… | 2020-09-01 |
| 952 | 952 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 623 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to give the resident and the resident representative in writing a notice of transfer in a language understood for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence of notice of transfer given to resident and resident representative. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident or the resident representative received a written notice of transfer. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he confirmed the transfer forms were not issued to the resident or the resident representative. | 2020-09-01 |
| 953 | 953 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 625 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to issue a bed hold notice to the resident representative upon discharge for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence a bed hold notice was issued. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident representative received a bed hold notice. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he stated a bed hold notice was not issued due to the resident being private pay. Review of the facility bed detail revealed all [AGE] beds were certified. | 2020-09-01 |
| 958 | 958 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 880 | D | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review, observation, interview, and review of facility policies titled Infection Control-Linen and Laundry, Infection Control Prevention and Control Activities, Infection Control-Linen and Laundry and information from ECOLAB, the facility failed to ensure infection control procedures were adhered to for one of one laundry observation and 2 of 2 handwashing observations. During observation of the laundry, staff was observed to carry a soiled gown close to his/her uniform, no separation between clean and soiled items in the personal laundry room. In addition, two observations were made of staff entering a soiled utility room and exiting without washing or sanitizing his/her hands. The findings included: During observation of the laundry on [DATE] at 8:30 AM, Laundry Staff #1 was observed after removing a soiled gown to hold it close to his/her uniform. Observation of the laundry for personal care items revealed one door entering into a small laundry room. To the right of the door soiled items and washers were observed. To the left of the door clean items and dryers were observed. Staff was observed entering the laundry with the soiled bin and clean, uncovered items were stored within 6 inches of the doorway. Measurements from the dirty laundry bin to the clean items was approximately 7 feet 2 inches. Due to the proximity and crowded area in the laundry, Laundry Staff were asked how did s/he manage to get clean items into the dryer. S/he stated the laundry racks were moved back. This placed the clean racks midway and very close to the soiled side of the room. In addition, Laundry Staff was observed to obtain the water temperature of the washer which was 125 degrees. S/he tested the pH of the linen and stated some days it is yellow and some days it is green. When Laundry Staff #1 was asked what the parameters for the water temperature and pH should be, s/he was unable to tell the surveyor. On [DATE] at … | 2020-09-01 |
| 1775 | 1775 | PRUITTHEALTH-MONCKS CORNER | 425140 | 505 SOUTH LIVE OAK DRIVE | MONCKS CORNER | SC | 29461 | 2017-10-05 | 282 | D | 1 | 0 | M91211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Base on observations, interviews and record review the facility staff failed to follow the care plan for falls for 1 of 10 residents reviewed for care plans. Resident #9 identified as being at risk for falls was noted with none of the care planned interventions in place. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] that coded the resident as having a BIMS (Brief Interview for Mental Status) of 9. The resident was coded as having clear speech. S/he required extensive assist with one person assist with activities of daily living; s/he needed limited assist of one with walking in the room. A wheelchair was used for ambulation. An Annual MDS dated [DATE] coded the resident as having a BIMS of 8. S/he required limited assist with one person assist with activities of daily living and ambulation; a wheelchair was used by the resident. One to two falls were noted during the assessments, no injuries were described. Review of the resident's care plan reveled a care plan with a problem onset date of 03/25/2014 that identified a risk of falls related to psychoactive medication use, impaired mobility, a history of falls, [MEDICAL CONDITION] and dementia. Interventions included staff to assist with transfers, bed alarm on at HS (hour of sleep) 4/7/2016 chair alarm when out of bed (OOB) . Observation during the initial tour on 10/03/2017 at approximately 5:05 PM revealed Resident #9 was not in his/her bed. The surveyor knocked on the bathroom door and no response was noted, the surveyor asked the 300 Unit Manager to come to the resident's room. The Unit Manager found the resident in the bathroom and assisted him/her back to bed. The bed was noted with an alarm control attached to the bedrail, no alarm was noted in the resident's wheelchair. The Unit Manager was not aware if the resident was at risk for falls; two other lic… | 2020-09-01 |
| 728 | 728 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2017-09-22 | 323 | E | 1 | 0 | MJSH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Observation, record reviews, interviews and review of the facility policy titled, Behavior Management, the facility failed to ensure a wander guard was in place at time of admission for Resident #174 with a history of wandering and exit seeking for 1 of 1 resident reviewed for Behaviors. The facility further failed to ensure safe use of a Hoya lift on the 200 Unit for 1 of 2 residents reviewed for Accidents. The facility additionally failed to ensure a door to electrical equipment was secure on the 200 Unit for 1 of 4 Units observed. The findings included: The facility admitted Resident #174 with [DIAGNOSES REDACTED]. Review on 9/20/2017 at approximately 11:37 AM of the Nurses Notes dated 3/28/2017 through 5/18/2017 states, Roams aimlessly, stands near exit doors and pushes. Goes to unit door and stands in doorway but does not leave. Resident is redirected out of other resident rooms, balls fist up at this nurse . Agitation and constantly trying to get out of the facility. Will wander into resident's rooms and stand by the exit doors. Will resist care at times and is hard to redirect. No interventions during that time were put in place to ensure exit seeking behaviors were reduced, prevented and monitored. Review on 9/20/2017 at approximately 11:45 AM of the physician's phone orders dated 4/9/2017 revealed an order to check wander guard function each shift and to check wander guard placement each shift. Further review on 9/20/2017 at approximately 11:55 AM revealed no other orders for a wander guard to be placed prior to 4/9/2017. During an interview on 9/20/2017 at approximately 1:35 PM with the Consultant MDS (Minimum Data Set) assessment coordinator he/she stated, I came in to help update the care plans on 5/18/2017. Resident #174 was in the hospital due to uncontrollable behaviors, and he/she was on bed hold. The Consultant MDS Coordinator went on to say that the physician had written an order for [REDACTED].#174 was exit seeki… | 2020-09-01 |
| 2904 | 2904 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 280 | E | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) with responsibility for individual residents participated with the development and/ or revision of the care plan for 7 of 22 residents reviewed. Residents #13, #[AGE], #[AGE], #154, #36, #57. In addition Residents #154 and #57 identified with pressure ulcers failed to have their care plans reviewed and revised with interventions to prevent further skin breakdown and/or falls. Two of two residents reviewed for pressure ulcers. The facility also failed to implement interventions to prevent further skin tears and falls for Resident #158, 1 of 3 residents reviewed for accidents. A therapy evaluation was not done timely after a fall on 01/23/17 and no new interventions were implemented following a fall on 02/08/17. In addition, no interventions were implemented to prevent skin tears. The findings included: During Record Review the care plan meeting attendance form for Residents # 13 and # [AGE], the CNA's did not attend the care plan meeting, 09/19/2017 12:01:40 PM - Interview DON- The CNA's don't attend the care plan meetings, the nurses do. DON unaware that care plan meetings were to be attended by the CNA's, stated ,Our Administrator gets all those memo's and I don't so I don't know to implement them. During review of the medical records on 9/20/17, it was discovered Resident #[AGE] did not have a Certified Nursing Assistant (CNA) in attendance at the Care Plan meetings. An interview conducted on 9/20/17 at approximately 3:56 PM with the Director of Nursing stated that CNAs were not actually attending the care plan meetings. Review of the Care Plan attendance sign in sheets showed there was no place on the form for CNAs to sign. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review revealed the Care Plan Conference attendance form dated 7/13/17 included spaces for attendee signatures. Further review of the form reveale… | 2020-09-01 |
| 2902 | 2902 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 225 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review, Facility Policy and Interview, the facility failed to report an incident timely within the 2 hour time frame to the State Agency. The findings included: The facility admitted resident # [AGE] on November 26, 2010 with diagnoses, including but not limited to, Dementia with behavioral disturbances, history of falls, [MEDICAL CONDITION], Cognitive communication deficit, muscle weakness, oral dysphagia, Major [MEDICAL CONDITION], Anxiety disorder, other secondary [MEDICAL CONDITION], Primary generalized [MEDICAL CONDITION] and [MEDICAL CONDITION] not due to to a substance or known physiological condition. During review of the 24 hour Incident Report dated 05/11/2017, documentation showed that the date and time of the Reportable Incident was 05/03/2017. The 24 hour was dated 05/11/2017 and the 5- day follow up was dated 05/14/2017. The weekend nurse was requested by the resident's son on 05/03/2017 at approximately 5-6 PM to evaluate the resident's ring finger on the right hand. Upon assessment, the nurse discovered dried blood on the residents right hand with a dressing intact and the fourth digit was crooked and swollen. A communication form was placed in the Communication Book for the Physician. The Nurse Practioner ordered an x-ray on 05/06/2017 which was positive for a right hand fourth digit middle phalanx head and neck fracture. | 2020-09-01 |
| 2753 | 2753 | CAPSTONE REHABILITATION AND HEALTHCARE | 425298 | 1850 CRESTVIEW ROAD | EASLEY | SC | 29642 | 2017-08-28 | 314 | G | 1 | 0 | 29HN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #4 and inaccurately documented the status of a Stage IV pressure ulcer as a Stage II for Resident #3, 2 of 3 residents reviewed for pressure ulcers. The findings included: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed the MDS (Minimal Data Set) coded Resident #4 as requiring extensive assistance to total dependence for all aspects of ADLs (Activities of Daily Living). Review of the Physicians Orders on 08/24/2017 revealed an order dated 06/08/17 for Sureprep to intact blister left outer heel q (every) shift until healed. Additional review revealed an order dated 06/20/17 for a [MEDICATION NAME] dressing to the left heel every Tuesday and Friday for an Unstageable ulcer and on 06/27/17 an order was received to apply [MED] 250 units per gram to eschar, cover with non-adherent pad and wrap with [MEDEQUIP]. On 08/24/17 at 12:17 PM, review of the care plan dated 06/12/17 revealed problem areas included, but were not limited to, Impaired Functional Mobility related to recent [MEDICAL CONDITION] dated 05/31/17. Interventions included assisting with ADLs, assisting with oral care, call light within reach and encourage resident to call for help as needed, PT (Physical Therapy) to evaluate and treat, remove staples in 14 days, and two 1/2 siderails up as needed for increased bed mobility. Further review revealed a care plan dated 06/09/17 for Potential/actual impairment of skin integrity including an intact blister to the left outer heel. Interventions included floating the heels initiated 06/08/17. There were no interventions to prevent pressure ulcers prior to 06/08/17. On 08/24/17 at 12:28 PM, review of the Evaluations revealed a Braden Scale completed 06/01/17 with a score of 14, indicating moderate risk of developing a pressure ulcer. No interventions were im… | 2020-09-01 |
| 4041 | 4041 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 328 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an observation, interview and review of the facility policy titled, Medication Administration: Enteral Tubes, the facility failed to confirm placement of and flush a [MEDEQUIP] tube for Resident #178 prior to administering a medication via the tube. The facility further failed to ensure the correct tube feeding was infusing as ordered by the physician for Resident #178 for 1 of 1 resident observed with a [MEDEQUIP] tube. The findings included: The facility admitted Resident #178 with [DIAGNOSES REDACTED]. An observation on 9/7/2017 at approximately 11:45 AM, during wound care for Resident #178, Licensed Practical Nurse (LPN) #4 administered a pain medication via a [MEDEQUIP] tube without first checking for placement and flushing the [MEDEQUIP] tube with a physician ordered water flush. During an interview on 9/7/2017 at approximately 11:48 PM with LPN #4 it was verified that placement had not been checked and the water flush was not done for Resident #178 prior to administering a medication via a [MEDEQUIP] tube. Review on 9/7/2017 at approximately 1:48 PM of the facility policy titled, Medication Administration: Enteral Tubes, number 8 states, Enteral tubes will be flushed before administering medications with 15 mls (milliliters) of water, with 5 mls of water after each medication, and 15 mls at completion of the medication administration. Flushes may be changed due to physician's order. Under, Scope: Procedure & Key Points, number 5 states, Verify tube placement using the following procedures: Inject 15 - 20 cc's of air into the tube with the syringe and listen to stomach with stethoscope for distinct whooshing sound. Aspirate stomach contents with syringe. Observations made on all days of the survey revealed Resident #178 with a tube feeding of Glucerna 1.5 at 45 cc's infusing hourly with a water flush of 125 centimeters every 4 hours. Review on 9/8/2017 at approximately 5:28 PM of a physician's order for Resident #178 dated 7/… | 2020-09-01 |
| 5158 | 5158 | MAGNOLIA PLACE - SPARTANBURG | 425175 | 8020 WHITE AVENUE | SPARTANBURG | SC | 29303 | 2016-04-21 | 514 | D | 1 | 0 | 77LK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, the facility failed to maintain clinical records that were readily accessible and systematically organized for 1 of 9 residents reviewed. Resident #19 failed to have readily accessible documentation related to her/his change in condition and admission to the hospital on [DATE]. The findings included: Resident #19 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the clinical record for Resident #19 revealed a Clinical Progress Note written by Activities dated 4/11/16 at 11:38 AM that stated, Neighbor sent out to hospital on [DATE] . and was not a bed hold. Further review of the clinical record revealed a note by the nursing staff dated 4/4/16 at 3:23 PM that stated, Resident confused and agitated. Trying to get up, talking to people that are not there. Notified Nurse Practitioner . new TO (telephone order) rec'd (received) for ua (urinalysis) with c&s (culture and sensitivity). This review failed to show a rationale for why or when the resident was sent to the hospital on [DATE]. In an interview with the surveyor on 4/18/16 at approximately 3:00 PM the Director of Nursing (DON) was asked to provided additional information about Resident #19's hospital admission on 4/4/16. S/he stated that s/he had assessed the resident and found her/him to be confused, not at her/his baseline. S/he stated that Resident #19's husband was in the facility and agreed the was not her/his usual self. The Director of Nursing stated s/he would need to look for the SBAR and her/his note to the hospital. The information was found after the DON looked through several large stacks of resident information in her/his office. | 2019-04-01 |
| 1027 | 1027 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2019-11-07 | 656 | D | 1 | 0 | QOW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident reviewed for a toileting program (Resident #8). The resident was assessed as incontinent for bowel and bladder but did not have an assessment completed to determine candidacy for bowel and bladder retraining. There was no care plan developed to address this need. The findings included: Review of the facility's Bowel and Bladder Assessment Policy, revised 5/2007 documented the following: Procedures: 1. Resident's care plan will be updated accordingly 2. Residents will be re-evaluated by the Interdisciplinary Team (IDT) quarterly and when a significant change occurs. Review of Resident #8's record revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment for determining the resident's attention, orientation and ability to register and recall new information was conducted. The resident scored 15/15, indicating that the resident was cognitively intact. The resident was assessed as requiring extensive assist with bed mobility, transfers, dressing, toileting and personal hygiene with 1-person physical assist. The resident was also assessed as having occasional urinary incontinence and frequent bowel incontinence. Review of the resident's care plan dated, 10/14/19, revealed the resident was care planned for the following: ADL Self Care Performance Deficit related to Limited Mobility; Hypertension; Anticoagulant use related to history of [MEDICAL CONDITION] Embolism; Potential for Constipation and [DIAGNOSES REDACTED]. Further review revealed that there was no care plan for incontinence. Record review revealed that no bowl and bladder assessment was conducted from admission on 10/11/19 to current … | 2020-09-01 |
| 1028 | 1028 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2019-11-07 | 690 | D | 1 | 0 | QOW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to ensure that a resident experiencing incontinence received appropriate assessment, treatment and services to prevent decline or to restore as much normal bladder function as possible for 1 of 1 sampled resident (Resident #8). The facility was unable to provide documentation that any type of restorative program was attempted and/or implemented. The findings included: Review of the Incontinence Managing Guidelines, Revised 11/2007 noted: All incontinent residents should be evaluated on admission and on condition change for potential incontinence management program Review of the facility's document titled Bowel and Bladder Assessment Policy, with a revision date of 5/2007 documented: It is the policy of this facility that a Bowel and Bladder assessment will be completed within the first fourteen (14) days of admission. Purpose: The purpose of the bowel and bladder assessment is to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence. Procedures: 1. A bowel and bladder assessment will be completed by day fourteen (14). 2. Resident's care plan will be updated accordingly 3. Residents will be re-evaluated by the Interdisciplinary Team (IDT) quarterly and when a significant change occurs. Review of Resident #8's record revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 was assessed to have intact cognition. The resident was assessed to require extensive assistance with bed mobility, transfers, activities of daily living (ADLs), toileting and personal hygiene. The resident was also assessed as being occasional incontinent of urine and frequently incontinent of bowel. Review of the skilled nursing progress note… | 2020-09-01 |
| 209 | 209 | WHITE OAK MANOR - SPARTANBURG | 425024 | 295 EAST PEARL STREET | SPARTANBURG | SC | 29303 | 2017-06-08 | 314 | D | 1 | 1 | FPCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review and interview the facility failed to do skin assessment sheets or wound documentation for December 2016 and January 2017 for Resident # 16. ( 1 of 2 residents reviewed for pressure ulcers.) The findings included: The facility admitted Resident # 16 with [DIAGNOSES REDACTED]. In connection with a family concern related to possible skin breakdown, documentation for any previous skin breakdown and skin assessment sheets were looked for in the medical record. No documentation could be found. During an interview with the Nurse Consultant on 6/7/17 at 12 Noon, the consultant stated there were no sheets available for skin audits or wound assessments for December 2016 and January 2017. A Quality Assurance Problem was identified by the facility and corrective action plan put into place on 5/23/17. The family concern was identified in January, 2017. At that time the facility was not doing daily skin sheets or weekly wound documentation. The family member brought to the attention of the nurse on 12/22/16 an area of broken skin on Resident # 16's left heel. The nurse assessed the area, called the physician, and treatment started. The calloused area on the left heel had begun to break down but not completely. There was a circular area of red skin underneath. The physician ordered the skin to be left in tact, skin prep, and a border foam ordered for every other day. The area was documented as healed on 1/20/17. | 2020-09-01 |
| 4987 | 4987 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2016-06-16 | 314 | G | 1 | 0 | XYM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, record review, observation, staff interview, review of facility policy the facility failed to ensure that 2 residents (Residents #1 and #2) of 9 sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically, the facility: -Failed to identify and implement measures to promote healing for existing pressure sores. - The facility failed to timely implement measures for preventing development of new pressure ulcers. -The facility ' s failures contributed to the delay in healing and worsening of the resident ' s pressure ulcers. The findings include: The facility Wound Care Policy (dated 10/2010) documents the purpose of this procedure is to provide information regarding the identification of pressure ulcers risk factors and interventions for specific risk factors. Item #6 documents the facility should have a system/procedure in place to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, ad family and addressed. 1. [AGE] year-old sample Resident #1 was originally admitted to the facility on [DATE]. The facesheet indicated Resident #1 s most recent admission from the hospital to facility was on 11/20/15. The resident was admitted for therapy treatment . A hospital physician discharge summary dated 11/20/15, indicated resident #1's primary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for skilled therapy. RECORD REVIEW: MINIMUM DATA SET (MDS) According to the most recent MDS, dated [DATE], Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. The MDS indicated the resident refused care at times and had a catheter in place. Resident #1 had a stage 1 or higher pressure ulcer with three unstageable deep tissue injury pressure sores on admission. The MDS indicated Resident #1 had pressure u… | 2019-06-01 |
| 3960 | 3960 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2019-04-19 | 689 | J | 1 | 1 | LJH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, and review of the facility's investigation, the facility failed to provide adequate supervision for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to assess elopement risk and implement interventions in a timely manner resulting in Resident #45 wandering out of the facility on three separate occasions (9/2/2018, 9/7/2018, and 9/17/2018). On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident on admission with a Brief Interview for Mental Status (BI[CONDITION]) score of 3 indicating severe cognitive impairment. Resident #45's Wandering/Elopement Risk Screening dated 8/21/2018 documented a score of 0 out of 0-9 with 9 being the highest risk. Record review revealed the 08/23/2018 nurses notes for Resident #45 documented that the resident was wandering in room and hallways and calling for his/her son/daughter. Acts of diversion and reorientation were used as requested by the son/daughter. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of the 9/2/2018 nurses' notes revealed Resident #45 wandered outside at midnight stating that s/he was unsure of where s/he was. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of Resident #45's nurses notes dated 9/7/2018 revealed Resident #45 wandered from the facility down the road and across the street. The facility courtesy officer went on a golf cart and brought the resident back to th… | 2020-09-01 |
| 3967 | 3967 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2019-04-19 | 835 | J | 1 | 1 | LJH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, review of the facility's investigation, and review of the facility's policy titled Wandering, Unsafe Residents, the facility failed to be administered in a manner to prevent elopement for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to adequately assess wandering/elopement, implement interventions for elopement, and provide education to all staff on the 400 and 500 units to prevent further elopement by Resident #45. On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 was admitted with a BI[CONDITION] (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. Review of nurse's notes dated 8/21/2018 through 9/19/2018 revealed Resident #45 wandered out of the facility on 9/2/2018, 9/7/2018, and 9/17/2018. Review of Resident #45's care plan revealed it did not include new interventions after the elopement on 9/2/2018. Review of Resident #45's care plan after the 9/7/2018 elopement revealed a wanderguard device was added as an intervention. Review of the 9/17/2018 nurses' notes revealed Resident #45 was found outside of the facility and a wanderguard was placed. No new interventions were documented. During an interview with the facility Administrator on 04/17/2019 revealed s/he did not recall the incident on 9/7/2018. The Administrator stated s/he had been employed there approximately a week. S/he stated, we try so hard not to restrict residents' movement. During an interview with the Director of Nursing (DON) on 4/17/2019 confirmed documentation in the nurses notes of th… | 2020-09-01 |
| 1383 | 1383 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2018-06-27 | 609 | D | 1 | 0 | TMQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility file review and interview, the facility failed to immediately report an incident of alleged abuse for 1 of 4 residents reviewed for abuse/neglect. Resident # 3 was allegedly struck by a staff member. The witness to the incident did not report the incident until the next day. The findings included: The facility admitted resident #3 on 1/29/17 with [DIAGNOSES REDACTED]. Review of the Facility investigation revealed on 5/16/18 at approximately 6:30 PM, resident #3 could not be found for dinner. Resident was found in another resident's room in another resident's bed. The Certified Nursing Assistant (CNA) and Activity Assistant (AA) attempted to get resident out of bed and walk her/him to the dining room. The resident was resistant and began to strike out at the CN[NAME] The Activities Assistant (AA) reported the resident was hitting out. The CNA, allegedly told the resident, if you hit me I'll hit you back. The CNA then reportedly hit the resident with open hand on the resident's arm and caused a small red area. The Activities Assistant left the room, leaving the resident and the CNA alone in the room. The AA did not report the alleged abuse until the next day, 5/17/18. 6/21/18 9:30 AM: Resident observed in the bed lying on right side, with bed covers pulled up to face. Resident dressed in street clothes. Right 1/2 rail elevated. Resident with eyes closed. Did not respond to knocking on door or calling resident's name. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 3/23/18. Brief Interview for Mental Status (BIMS) was scored a 6 out of 15. No mood or behavior problems. S/he required supervision with most of her/his Activities of Daily Living, independent with eating, extensive assist with dressing and bathing, and limited assistance with hygiene. S/he was 64 inches tall and weighed 120 pounds. S/he received antipsychotic medications. physician progress notes [REDACTED]. Resident is unable to rememb… | 2020-09-01 |
| 1233 | 1233 | EDISTO POST ACUTE | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2019-04-18 | 610 | D | 1 | 1 | Y2KT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files and interview, the facility failed to have evidence that all alleged violations were thoroughly investigated. The facility did not thoroughly investigate an injury of unknown origin for Resident #[AGE]5 and an allegation of mental abuse for Resident #[AGE]7 (2 of 6 residents reviewed for abuse). The findings included: The facility admitted Resident # [AGE]5 on 1[DATE]17 with [DIAGNOSES REDACTED]. Review of the facility files revealed that on 03/15/2019 the facility noted a discolored area on the resident's left upper thigh and facial grimacing when touch. The facility sent the resident to the emergency room for evaluation. In the facility file there was only four statements from staff. During an interview on 04/17/2019 at 4:00 PM, the Director of Nursing (DON) confirmed that only four statements were obtained during the investigation. The facility admitted Resident #[AGE]7 on 10/13/18 with [DIAGNOSES REDACTED]. During the investigation of a Facility-Reported Incident, review of the Five-Day Follow-Up Report revealed the incident occurred on 10/19/18 at 07:20 PM. Further review revealed a statement from the alleged perpetrator. No staff statements, other than the alleged perpetrator, were obtained by the facility. Review of the assignment sheet dated 10/19/18 revealed the alleged perpetrator was listed on the schedule from 3:00 PM until 11:00 PM on that date. The assignment sheet also showed another Certified Nursing Assistant was also listed and assigned to the same group. During an interview on 04/18/19 at 02:15 PM, the DON neither confirmed nor denied that the incident was not reported timely, was not thoroughly investigated, or the that the facility failed to follow their policy related to reporting and investigating. The facility's Abuse policy was reviewed during the recertification and complaint survey. Review of the policy Abuse Investigation and Reporting revealed Role of the Investigator: 1. The individual c… | 2020-09-01 |
| 3435 | 3435 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2017-07-12 | 223 | D | 1 | 0 | OJU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files and interviews, the facility failed to protect 1 of 1 residents from verbal abuse. Resident #1 was involved in an altercation with a Certified Nursing Assistant (CNA), and was threatened with physical harm. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the facility reported investigation revealed the resident was involved in an altercation with a CN[NAME] The facility investigation revealed on 12/18/2016 at approximately 3:00 PM, the resident was cursed and yelled at by the CN[NAME] The CNA threatened to tie the resident's catheter around the resident's neck. Nurses Notes reviewed from 12/2/16 through 1/28/17: Resident was noted to be alert and oriented, cooperative with care and no behavior issues. There were no nurses' notes regarding the alleged incident of 12/18/16. On 7/10/17 at approximately 5:00 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The LPN stated s/he could not give the name of the CN[NAME] I do remember the resident and the CNA were arguing back and forth. The two of them were threatening each other. They were at the nurses' station. I do remember s/he (CNA) said she would wrap the foley around her/his (resident's) neck. I don't know how it started or what led up to that. On 7/10/17 at approximately 5:20 PM, LPN #2 was interviewed by the surveyor. I don't remember the CNA's name. I heard her/him say something about wrapping her/his foley around her/his neck or hurting her/him in some type of way. S/He had said something about not giving her/ him a proper bed bath or proper shower or something like that. Me and the staff went up and separated them 7/11/17 at 8:15 AM, Resident #1 was observed in bed with blanket pulled over her/his head. Resident was alert and oriented. The resident was interviewed by the surveyor. It was my shower day. Someone told her/him s/he didn't have any showers to give. S/he left me in my room in my bed. S/… | 2020-09-01 |
| 1442 | 1442 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 568 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files reviewed and interviews, the facility did not provide quarterly statements to residents with facility maintained accounts for multiple residents. The findings included: The facility reported to the state agency an allegation of misappropriation on [DATE]. A visit was made to the facility to investigate the allegations. At the time of the investigation on [DATE] the facility did not have the investigation at the facility. During the Entrance Conference, the Administrator informed the surveyor, s/he had only been at the facility for approximately three (3) weeks and the Corporate Office handled the investigation. The Administrator was aware of the incident but did not know the specifics. The facility District Director of Business Office Services stated that 21 resident accounts were involved. Then stated there were 11 resident accounts affected. Their investigation showed only six residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident that deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts Receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. Residents did not receive quarterly Bank statements or statements when requested. At Approximately 12:30 PM on [DATE], the corporate representative, District Director of Business Office Services, was interviewed by the surveyor. We restructured in November of 2016, and I got these buildings. I provide support and training to Business Office Staff and audit annually and as needed per company policy. Every month the Business Office prepares a copy of all patient trust transactions, withdrawals, deposits, checks and it is s… | 2020-09-01 |
| 3547 | 3547 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 758 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observations, record reviews, and interviews the facility failed to ensure that one (Resident (R) 109) of five residents reviewed for unnecessary medications had adequate indications for use of an antipsychotic medication, [MEDICATION NAME]. Resident (R) 109 was receiving [MEDICATION NAME] without an adequate indication for its use. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use, dated (MONTH) (YEAR), revealed Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Review of R109's undated Face Sheet, found in R109's electronic medical record (EMR) under the [DIAGNOSES REDACTED]. Review of a Physicians Order dated 10/10/18, found in the Orders section of the EMR indicated quetiapine [MEDICATION NAME] ([MEDICATION NAME]) give 1 tablet by mouth in the evening for depression, agitation. This was then discontinued on 10/24/18. Review of a Pharmacy Consultation Report dated 10/11/18, found in the closed thinned portion of the medical record indicated (Name of R109) receives an antipsychotic, quetiapine, but does not have a supporting indication for use documented. Physician's response: See Psych notes 10/24 to 11/2 with [DIAGNOSES REDACTED]. Review of a Psychiatric Evaluation dated 10/24/18, found in the closed thinned portion of the medical record indicated [DIAGNOSES REDACTED]. Recommendations: Continue medication(s) as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effects. Dose reduction attempted and/or reduction will cause decompensation of patient. Review of a Physicians Order dated 01/02/19, found in the Orders section of the EMR indicated [MEDICATION NAME] give 100 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION] and MDD (major [MEDICAL CONDITION]). Review of a Physicians Order dated 01/14/19, found in the Orders section of th… | 2020-09-01 |
| 4015 | 4015 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2018-05-24 | 609 | E | 1 | 0 | V9CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility records and interviews, the facility failed to report incidents of alleged abused and/or falls with serious injury timely for 2 of 3 reportable incidents reviewed. Resident #1, #2, #3 and #4 with allegations of abuse and fall with major injury were not reported to administration immediately. The findings included: In response to complaints and reportable incidents received by this office an investigation was conducted into the allegations. The facility admitted resident #1 with [DIAGNOSES REDACTED]. On 5/23/18 at 11:15 AM the resident was observed in wheel chair in room watching TV. The resident's call light was observed to be in reach and activated. Resident alert and pleasant, requesting to go to bathroom. Resident of small thin fragile appearance. Review of the medical record revealed a care plan for falls. Potential for fall related injury related to cognitive loss, dementia, medications that can alter alertness, history of falling with right clavicle fracture. Monitor for changes that may warrant increased supervision/assistance. Call bell within reach and answer promptly, alarms in bed and wheelchair, proper fitting shoes, assist with transfers, dycem to wheelchair. Falls care planned from 7/20/17. Updated 11/25/17, fall no injury, 12/17/17 No further falls, 2/12/18 fall with injury. Review of the Nurse's Notes revealed on 2/11/18: Resident reported to son/daughter that he/she fell in the garage and in the hallway. Son/Daughter stated resident had fallen in the garage at home, years ago. Resident complained (c/o) pain to right hip during the assessment. Resident pointed to right shoulder. Right shoulder observed with dark bluish discoloration with fading yellow. Resident reported pain with facial expressions, Pain scored at 2/10. [MED] 325 milligrams (mgs) one tab given. Doctor was notified. Order obtained for x-ray of the right shoulder, clavicle area to be completed on Monday, 2/12/18. 2/12/18: Doctor notified of x… | 2020-09-01 |
| 4063 | 4063 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 520 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 11:45 AM that Immediate Jeopardy existed at CFR4[AGE].[AGE] F-520 at a scope and severity level of (J) beginning on [DATE]. The facility failed to identify quality deficiencies related to 2 of 3 sampled residents reviewed for death in the facility for whom cardiopulmonary resuscitation (CPR) was not provided as required. The facility failed to implement a plan of action related to Advance Directives for and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure residents who exhibited absence of pulse and respirations received CPR when indicated and according to State Law resulted in Immediate Jeopardy for Residents #205 and #210. It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resusci… | 2020-09-01 |
| 4056 | 4056 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 490 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, the facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation for 2 of 3 sampled residents reviewed for death in the facility. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide cardiopulmonary resuscitation (CPR). The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide… | 2020-09-01 |
| 2552 | 2552 | HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA | 425289 | 1800 EAGLE LANDING BLVD | HANAHAN | SC | 29406 | 2018-04-14 | 584 | D | 1 | 1 | N9KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on initial tour and subsequent observations, the facility failed to maintain a sanitary homelike environment for 3 of 3 nursing units. Furthermore the facility failed to create a clean and homelike environment for Resident #11 . The findings included: During environmental rounds with the Administrator and the Maintenance Director on 04/14/18 at 2:28 p.m. the following findings were confirmed from the initial tour on 04/09/18 and 04/10/18: 1. room [ROOM NUMBER] -Left panel of the sink's countertop was peeling away - Brown splatter under the light switch in the restroom -Paint peeling away where the railing is affixed to the wall in the restroom 2. room [ROOM NUMBER] - wall above Heating Ventilation and Air Conditioning unit in disrepair 3. room [ROOM NUMBER] B -Dried splatter on the foot board Observations on 4/10/18 at 3:30 PM and throughout 5 days of the survey revealed that Resident #11 had no personal items in his/her room and there were brown spots/fingerprints all over the hall wall next to the bed. During an interview on 4-13-18 at 12:06 PM, Licensed Practical Nurse (LPN) #2 checked the room wall and verified multiple areas of brown substance on the wall. Observation on 04/11/18 at 09:13 AM revealed that Resident #11's wheelchair frame had a heavy dust build up and dried spills on the sides. This was verified by the Activities Assistant who stated s/he would get someone to clean it. During the Resident Council Meeting on 4/11/18 at 2 PM, Resident #9 complained that staff never made his/her bed. When Resident Council members were asked if they got their beds made, 2 of the 7 active participants stated they had to make their own bed if they wanted it done. Three residents stated they never got their beds made. In addition, for 5 days of the survey, Resident #11's bed was only made up with sheets, no blanket or spread. During an interview on 4/13/18 at 5:30 PM, the Administrator verified that Resident #11's room was bare and the be… | 2020-09-01 |
| 1456 | 1456 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 756 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that any irregularities in medication orders were identified by the pharmacist during monthly reviews. This irregularity should then be addressed by the attending physician/nurse practitioner and the Director of Nursing Services (DNS). This failed practice affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility 05/16/17 with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders [REDACTED]. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN) #100. The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. An interview was conducted with the Consultant Pharmacist, (PharmD #115), on 01/13/20 at 4:28 PM concerning the order for [MEDICATION NAME] written for Resident #35 on 11/13/19. PharmD #115 was asked if the way this order for a psychoactive medication was written was okay. She stated, I must hav… | 2020-09-01 |
| 1457 | 1457 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 758 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that physician's orders for a psychoactive medication ([MEDICATION NAME], an antianxiety medication) was written with a frequency for administration and a stop-date for the prescription, not to exceed 14-days. This affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders observed was for [MEDICATION NAME] (an anti-anxiety medication), [MEDICATION NAME] - Schedule IV solution; 2 mg/mL (milligrams/milliliter; amt (amount): 1 mg; injection. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN #100). The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. | 2020-09-01 |
| 1483 | 1483 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2017-10-23 | 499 | D | 1 | 0 | M6T211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to employ qualified staff. Licensed [MEDICATION NAME] Nurse (LPN) #1 was hired before his/her criminal background check had been completed. The findings included: Review LPN #1's employee file on 10/23/17 at approximately 12:20 PM revealed LPN #1 was hired on 12/3/2003. The employee's criminal background check was completed on 12/11/2003 and revealed the following prior charges: assault and battery, possession of marijuana with intent to distribute, and harassment. Interview with Financial Coordinator on 10/23/17 at approximately 12:30 PM confirmed that LPN #1 was hired before completion of the criminal background check but after commencement of the criminal background check (12/1/2003). | 2020-09-01 |
| 2778 | 2778 | RICHARD M CAMPBELL VETERANS NURSING HOME | 425301 | 4605 BELTON HIGHWAY | ANDERSON | SC | 29621 | 2018-04-19 | 607 | D | 1 | 1 | 2DMF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure staff followed protocol for caring for difficult and combative residents. Certified Nursing Aide (CNA) #1 did not call for assistance or pause care when Resident #19 became combative, resulting in accidental or inadvertent physical contact for 1 of 1 resident reviewed for abuse. The findings included: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility Investigation on 4/17/18 at approximately 10:21 AM revealed the Resident #19 was combative while CNA #1 was obtaining vitals. The CNA inappropriately touched the resident's face. The resident was assessed with [REDACTED]. At the completion of the investigation it was determined that CNA #1 inappropriately touched the resident and was dismissed. Review of Facility Interviews on 4/17/18 at approximately 11:47 AM revealed CNA #2 entered the room of Resident #19 to assist CNA #1. S/he observed the CNA to grab the nose of the resident when s/he became combative and then slap the resident as s/he continued to be obstreperous. Facility Interview of CNA #1 confirmed s/he slapped the resident accidentally. Interview with CNA #2 4/17/18 at approximately 4 PM confirmed that she entered the room of Resident #19 to assist CNA #1. S/he witnessed the CNA grab the resident's nose when s/he became combative. When the resident continued to fight the CNA, s/he slapped the resident. CNA #2 confirmed the resident appeared unharmed. She confirmed she had never had prior care concerns from CNA #1. Abuse prohibition interviews were conducted throughout 4/19/18 with nursing staff. There were no concerns. All CNAs stated that if handling an obstreperous resident they would ensure safety, withdraw, ask for assistance, and reapproach. Interview with Director of Nursing (DON) on 4/19/18 at approximately 4:20 PM revealed CNAs were expected to walk away and/or ask for assistance when providing care to obstre… | 2020-09-01 |
| 3430 | 3430 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 684 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to follow physician's orders for 1 of 5 residents reviewed for unnecessary medications. Body mass index (BMI) for Resident # 40 was not taken as ordered by the physician. The findings included: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders for Resident # 40 on 10/2/18 at approximately 12:15 PM revealed the resident was ordered for [MEDICATION NAME] 5 mg twice a day and monitoring of BMI and waist circumference every 6 months if on an atypical antipsychotic. Review of vitals sheet on 10/2/18 at approximately 1:02 PM revealed missing BMIs. Interview with Registered Nurse #1 on 10/3/18 at approximately 10:02 AM confirmed the missing BMIs in the vitals sheet. S/he was unable to find documentation of BMI within the last 6 months. Interview with Registered Dietitian #1 on 10/3/18 at approximately 12:28 PM revealed the RD records the BMI in the body of the note but was unable to find a BMI within the last 6 months for Resident # 40. | 2020-09-01 |
| 2199 | 2199 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 609 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 residents residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 1/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to resident incident report that occurred on 01/14/19. Review of the facility's investigation record revealed the investigation into Resident #5's allegation of abuse was not initiated until 01/31/19 after the resident reported the allegation dire… | 2020-09-01 |
| 3660 | 3660 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2019-09-05 | 607 | D | 1 | 1 | 5P8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to implement the facility Abuse Policy to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of… | 2020-09-01 |
| 403 | 403 | BLUE RIDGE IN GEORGETOWN | 425048 | 2715 SOUTH ISLAND ROAD | GEORGETOWN | SC | 29440 | 2018-11-17 | 600 | J | 1 | 0 | H6ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse and neglect. Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for approximately 30 minutes during an evacuation. 2 of 2 CNA's reviewed for assignments. The facility failed to protect residents from sexual abuse. Staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. The facility failed to protect residents from verbal abuse. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. 3 of 10 residents sampled for abuse. The findings included: Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for an hour during an evacuation. Review of the facility assignment sheet for 9/11/18 revealed CNA #2 was assigned 12 residents and CNA #3 was assigned 10 residents. Review of the facility investigation on 11/3/18 at approximately 9:50 AM revealed that CNA #2 and #3 left their assigned residents without permission on 9/11/18 at approximately 10 AM. During an interview with the Director of Nursing (DON) and Chief Operations Officer (COO) on 11/3/18 at approximately 11 AM. The DON and COO stated that CNA #2 and #3 left the facility without reporting to supervisors. Review of 9/11/18 time card reports on 11/3/18 at approximately 11:38 AM revealed CNA #2 clocked out at 10:05 AM and CNA #3 clocked out at 9:50 AM. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The DON stated that the resident assignments were redone within 30 minutes of CNA #2 and #3 leaving. During an interview with the Human Resources Director on 11/3/18 at approximately 11:51 AM. The Human Resources Director confirmed interviews with the DON and COO and stated that resident care was affected because the facility was short-staffed during the evacuation.… | 2020-09-01 |
| 3916 | 3916 | THE ARBORETUM AT THE WOODLANDS | 425394 | 50 ARBORTEUM WAY | GREENVILLE | SC | 29617 | 2019-01-15 | 600 | G | 1 | 0 | DBL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse for 1 of 3 residents reviewed for abuse. Certified Nursing Assistant (CNA) #1 verbally and physically abused Resident #1. The findings included: The facility reported an allegation of abuse to the State Agency for physical and verbal abuse of Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 9/21/18 revealed the incident occurred on 9/19/18 between 5:31 AM and 6:00 AM. At approximately 6:11 AM Resident #1 reported to Licensed Practical Nurse (LPN) #1 that CNA #1 had slapped him/her and called him/her a name. Resident #1 was able to identify the CNA when given pictures of several staff members. Review of the facility's investigation revealed a statement by Resident #1 that indicated I got slapped. It was a (wo/man) and (s/he) slapped me in the left side of my face. (S/he) called me something it was not nice . Further review of the facility's investigation revealed a statement completed by the Director of Nursing (DON) on 9/20/18 related to witnessing Resident #1 provide a statement to the police related to the allegation of abuse. The statement indicated (Resident #1) was interviewed by two officers with this nurse present. (S/he) was presented with four pictures to which (s/he) stated No when pictures shown. Officers then brought in picture of accused and resident stated yes beyond a doubt. Resident stated that (CNA #1) called (him/her) a [***] and slapped (him/her) on the left side of my face. Review of the Incident/Accident Report dated 9/19/18 at 6:16 AM completed by LPN #1 revealed Resident #1 was at nursing station with this nurse when s/he stated (S/he) slapped me. After questioning s/he said that it was the girl/guy that got him/her dressed this morning. No injury/marks noted to face where resident showed staff where s/he was hit. Review of the Police Department Supplemental Report dated 9/19/18 revealed the office… | 2020-09-01 |
| 2869 | 2869 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2018-06-13 | 600 | D | 1 | 1 | 577J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse for 1 of 3 residents reviewed for abuse. Resident #23 was abused by Registered Nurse (RN) #2 on at least two separate occasions. The findings included: Resident #23 was admitted to the facility 6/3/16 with [DIAGNOSES REDACTED]. Review of RN #3's statement on 6/12/18 at approximately 9 AM revealed that RN #3 witnessed RN #2 yelling at Resident #23 on 9/10/17. RN #2 was shouting that the resident had to wear incontinence briefs because there was no clean underwear. Resident #23 was yelling back at RN #2 that s/he did not want to wear a diaper. Review of statement of Certified Nursing Aide (CNA) #1 on 6/12/18 at approximately 9 AM revealed that on 9/10/17 between 4 and 5 PM, Resident #23 had wet her/his clothing. RN #2 told Resident #23 that only babies wet their clothes and that s/he needed to wear incontinence briefs. RN #2 was also trying to force Resident #23 to pick up her/his mess. CNA #1 stepped in to help followed by RN #3. Review of statement of CNA #2 on 6/12/18 at approximately 9 AM revealed RN #2 told Resident #23 to pick up his/her clothes and put on incontinence briefs. When CNA #3 entered, RN #2 had already left and Resident #23 was on the bed fussing and crying. CNA #2 immediately contacted the Activities Director, who also had good rapport with the resident. Review of Social Worker (SW) #1's statement on 6/12/18 at approximately 9 AM revealed that it was reported on 9/11/17 that Resident #23 had defecated on the floor and RN #2 had ordered her/him to clean it up. A visitor witnessed this. Review of the Visitor's statement on 6/12/18 at approximately 9 AM revealed that the Visitor heard RN #2 raising her/his voice and ordering Resdient #23 to pick up something. RN #2 told the resident, We're going to stand here 'til you pick it up. This went on a long time. Review of the Facility's investigation file of the abuse on 6/12/18 at approximate… | 2020-09-01 |
| 3659 | 3659 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2019-09-05 | 600 | D | 1 | 1 | 5P8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck by Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of my hand on (his/her) left thigh lik… | 2020-09-01 |
| 3429 | 3429 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 623 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to provide written notification of transfer/discharge for 1 of 2 residents reviewed for hospitalization . Resident # 39 was discharged to the hospital on [DATE] but the facility did not provide written notification to resident representative or send a copy of notification to the ombudsman. The findings included: Resident # 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes on 10/2/18 at approximately 3:24 PM revealed the resident went out to the hospital on [DATE] to rule out aspiration pneumonia. No documentation that written notification was provided to the family was found in the resident's chart. Review of notification to ombudsman on 10/2/18 at approximately 4:10 PM revealed the ombudsman did not receive written notification of Resident # 39 transfer until 9/13/18. Interview with administrator on 10/2/18 at approximately 4:18 PM confirmed the ombudsman did not receive written notification until 9/13/18. Review of policy for notification of transfers to ombudsman and responsible party on 10/3/18 at approximately 9:19 AM revealed the following: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. | 2020-09-01 |
| 2889 | 2889 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 608 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to report a reasonable suspicion of a crime for 1 of 12 residents reviewed for abuse. Resident #24 made an allegation of abuse that was not reported to the police or state. The findings included: Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. Review of the facility Abuse Policy on 7/16/19 at approximately 2:05 PM revealed it is the responsibility of employees, facility consults, physicians, family, visitors, vendors or others to report any incident or suspected incident of neglect or resident abuse. | 2020-09-01 |
| 2892 | 2892 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 641 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility miscoded a Minimum Data Set (MDS) for 1 of 3 closed charts reviewed. Resident #384 was discharged to community but coded in MDS as acute hospitalization . The findings included: Resident #394 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of progress notes on 7/16/19 at approximately 3:49 PM revealed the resident was discharged home on[DATE] from his court hearing with the Department of Social Services. Interview with MDS Coordinator on 7/16/19 at approximately 4:04 PM revealed the MDS was coded in error and the resident should have been marked as discharge to community. | 2020-09-01 |
| 1373 | 1373 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2019-04-12 | 604 | G | 1 | 0 | 0Q9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, and review of the facility's policy titled, Use of Restraints, the facility failed to safeguard residents from the use of physical restraints for 1 of 1 residents reviewed for physical restraints (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report revealed on 3/19/2019 between 6:15 and 7 PM Resident #24 was found in bed with both the blanket and bedsheets wrapped tightly around the side rails of the bed. During an interview with Certified Nursing Assistant #2 on 4/10/19 at 5:54 PM, s/he demonstrated to this surveyor how Resident #24 was found in bed. S/he stated Resident #24 was attempting to get up, which is usually a sign that s/he needed to be toileted; however, when entering the room, s/he noticed both the blanket and sheets were tightly wrapped around the siderails on the bed, which the resident was not physically capable of doing him/herself. During an interview with the Director of Nursing on 4/10/19 at 4:19 PM, s/he indicated s/he had a conversation with the responsible party that the resident reportedly tied themselves in the bed before while at home. During an interview on 4/11/19 at 9:52 AM, Licensed Practical Nurse #2, s/he confirmed the resident was restrained by both the sheets and blanket in the bed. Review of the facility's policy titled, Use of Restraints indicates practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: tucking sheets so tightly that a bed-bound resident cannot move. | 2020-09-01 |
| 3542 | 3542 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 600 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to ensure that a resident was free from physical abuse. A resident, who required supervision due to aggression toward staff and other residents, was observed to have escalating behaviors, resulting in an altercation where Resident (R) 93 struck R 43 on 12/12/18. This deficient practice had the potential to affect two of 27 sampled residents reviewed. (Resident (R) 43 and R93). Findings include: Review of R93's Face Sheet in his/her paper chart revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment for R93, dated 10/19/18, documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Further review of the MDS did not indicate any behavioral symptoms. Review of R93's Care Plan revealed no behavioral problems had been identified or interventions initiated prior to 05/01/19. Review of R93's Interdisciplinary Team (IDT) Progress Notes in his Electronic Medical Record (EMR) revealed no documentation of altercations with other residents prior to 12/07/18. On 12/07/18 at 8:45 PM, an Incident Note in R93's EMR documented the resident was transferred from the[NAME]unit to the Angel Oak unit and placed on every 15-minute checks for three days. On 12/11/18 a Five Day Follow Up Report, provided by the facility's Administrator, documented R93 was the aggressor in a resident to resident altercation with his roommate on 12/7/18. The report documented R93 was moved to a different room, and his care plan was reviewed and revised. However, no revisions were documented on R93's care plan regarding the altercation, or the level of supervision required when R93 was in the proximity of other residents. On 12/10/18 at 7:40 PM, a Behavior Note in R93's EMR documented he had a verbal outburst with inappropriate language directed at staff, when they attempted to redirect the re… | 2020-09-01 |
| 300 | 300 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2017-05-11 | 278 | D | 1 | 1 | X7DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to accurately code the Minimum Data Set for 1 of 1 sampled resident reviewed for hospice. Resident #113 was not coded as having a terminal illness under J1400. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 5-10-17 at 12:36 PM, review of hospice certifications for 10-26-16 and 1-2-17 noted that the resident's life expectancy was less than 6 months. Review of the 11/14/16 Annual and 2/13/17 Quarterly Minimum Data Sets on 5/10/17 at 10:30 AM revealed that item J1400 was coded as 0 indicating that the resident did not have a life expectancy of less than six months. During an interview on 05/11/2017 at 9:27 AM, Licensed Practical Nurse #3 and Registered Nurse #1 verified the life expectancy was not coded correctly. MDS staff were not aware that the information was located in the hospice book. | 2020-09-01 |
| 2897 | 2897 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 604 | G | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident #4 was free from restraints, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/20/18, an incident occurred with Resident #4 and the Certified Nursing Aide (CNA) assigned to care for him/her that evening. Cross refer to F0[AGE]0. Resident #4 had a routine per CNA #2 and Licensed Practical Nurse (LPN) #1, to propel her/himself up and down the hallway, using the handrails for momentum until the hours of 2:00 a.m., before going to bed. Based on an interview with LPN #1 on 04/20/18, Resident #4 was in the solarium with CNA#1 and her/his wheelchair brakes were noted to be in the locked position. Per LPN #1, Resident #4 was not capable of locking/unlocking the brakes of her/his wheelchair. This information was consistent with the noted Activities of Daily Living (ADL) functionality indicated on the Minimum Data Set assessment dated , 01/23/18, indicated the resident required extensive assistance for most ADLs - bathing, dressing, grooming and total dependence for eating. LPN #1 instructed the aide to unlock the resident's chair and assist her/him to the restroom. During an interview with the Director of Nursing (DON), s/he stated the resident did not have any restraints in place and therefore would have no restraint assessments. | 2020-09-01 |
| 945 | 945 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2017-11-20 | 223 | D | 1 | 0 | ZQI511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure resident freedom from involuntary seclusion for 1 of 3 residents reviewed for seclusion. Resident #2 was involuntarily secluded in his/her room by Certified Nursing Assistant (CNA) #2 on 6/24/17. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:40 PM revealed the Risk Manager messaged the Greenville County Sheriff explaining that Resident #2 was involuntarily secluded by CNA #2 who was suspended. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:50 PM revealed that CNA #4 went to Resident #2's room several times because the call light was on and found each time that CNA #2 had blocked the door with the chair. S/he walked by the door once more and heard the doorknob turning. Believing that Resident #2 was trying to leave his/her room, CNA #4 informed the nurse. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:55 PM revealed that CNA #3 did not see anything, but heard knocking on the door of Resident #2's room. S/he believed it sounded like someone trying to leave the room. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 5 PM revealed that CNA #4 reported to Licensed [MEDICATION NAME] Nurse (LPN) #2 that Resident #2 was being confined to his/her room by CNA #2. LPN #2 forced open the door to find CNA #2 sitting in chair in front of door. LPN #2 explained that the door cannot be blocked. Resident #2 was found to be agitated and immediately left the room. Review of facility investigation of involuntary seclusion on 11/20/17 at approximately 8:40 PM revealed CNA #2 was with Resident #2 in his/her room and was encouraging him/her to finish his/her supper but the resident kept getting up and down. The tray was taken from the resident's room by… | 2020-09-01 |
| 645 | 645 | WHITE OAK MANOR - NEWBERRY | 425077 | 2555 KINARD STREET | NEWBERRY | SC | 29108 | 2017-07-19 | 318 | D | 1 | 1 | DYWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure restorative services were provided for 1 of 3 sampled residents reviewed for range of motion. Resident #147 with physician's orders [REDACTED]. The findings included: The facility admitted Resident #147 with [DIAGNOSES REDACTED]. A review of the medical record on 7/18/17 at approximately 10:48 AM revealed a physician's orders [REDACTED]. Further record review revealed a care plan that indicated resident was to receive PROM five (5) days a week to bilateral upper extremities every shift with a problem onset date of 9/2/16 with the next review target date of 10/03/17. The care plan also addressed Resident #147 receiving PROM to lower extremities times 10 reps three (3) days a week every shift. Further review of the medical record revealed PROM documentation for the months of 4/17/17 to 7/18/17 that indicated documented PROM services was provided to Resident #147 on 4/17/17 one shift, 4/18/17 one shift, 4/25/17 one shift and 4/27/17 one shift. The PROM for the month of May 2017 revealed documented services for 5/01/17 one shift, 5/02/17 one shift, and 5/03/17 one shift. The PROM for the month of June 2017 revealed services were provided on 6/15/17 one shift, 6/21/17 and 6/22/17 one shift. The PROM for the month of July 2107 revealed services were provided on 7/04/17 one shift, 7/11/17 and 7/12/17 one shift. An interview on 7/19/17 at approximately 11:40 AM with the Director of Nursing confirmed the restorative documentation as noted and further stated the blanks noted on the PROM documentation indicated the Certified Nursing Aide may not have been able to provide the services due to being called away. | 2020-09-01 |
| 1129 | 1129 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 561 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that 2 of 19 sampled residents (Resident #5 and Resident #6) were allowed to make personal choices and engage in intimate behavior in the privacy of their room. Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet in the Electronic Medical Record (EMR) revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located under the Care Plan tab of the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #6's face sheet, located under the Profile tab of the EMR revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment with an ARD of 09/23/19, located under the MDS tab of the EHR, revealed a BI[CONDITION] score of 13, indicating he/she was cognitively intact. Further review of the MDS revealed no hallucinations, delusions, or behavioral concerns. Review of Resident #6's care plan, located under the Care Plan tab of his EMR, revealed a focus which read, I have an alteration in mood (as evidenced by) inappropriate sexual behavior, added 10/01/18. The interventions inclu… | 2020-09-01 |
| 4050 | 4050 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 387 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the frequency of physician visits as required. Resident #22, Resident #42, Resident #156, Resident #95, Resident #[AGE], and Resident #207 did not have documented physician visits as required for 6 out of a total of 20 sampled residents reviewed. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed that the only Physician's Progress Notes in the medical record were on 12/16/16 and 8/24/17, after readmission from the hospital to the facility on [DATE]. No further evidence of physician visits were produced after requesting physician progress notes [REDACTED]. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 2pm revealed no evidence of physician visits on the chart. A request for medical records did not produce evidence of physician visits. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 9am revealed an unsigned progress note dated 7/22/16, a Physician's Progress Note dated 7/28/16 signed by an Advanced Practice Registered Nurse, and the progress note on the back of that note was dated 8/24/17. No further evidence of physician visits from 7/28/16 through 8/24/17 were produced after requesting physician progress notes [REDACTED]. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 2:30 PM of a form titled, Physician's Progress Notes, revealed the most recent note dated 11/02/2016. No other Physician's Progress Notes were found in t… | 2020-09-01 |
| 800 | 800 | MAGNOLIA MANOR - GREENVILLE | 425090 | 411 ANSEL ST | GREENVILLE | SC | 29601 | 2017-08-23 | 225 | E | 1 | 0 | FYRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to implement abuse prohibition policy in 2 of 3 abuse investigations reviewed. Suspected abuse of Residents #15 and #53 were not promptly reported by staff, and the direct consequence was delayed investigation. The findings included: An initial 24-Hour Report was sent to the Department of Health and Environmental Control on 8/1/17 regarding an allegation that Resident #15 was inappropriately touching another resident. Interview with Certified Nursing Assistant (CNA) #1 on 8/22/17 at approximately 6:15 AM revealed that s/he had observed Resident #15 touching other residents and staff inappropriately on 7/23/17 and 7/28/17. S/he stated that both times s/he reported the suspected abuse to a nurse but was unable to name which nurse. Review of facility policy regarding Abuse Prohibition on 8/22/17 at approximately 7:40 AM revealed the following: All alleged isolations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator, and to other officials in accordance with state law including the State Certification Agency (nurse aide registry or licensing authorities). The facility policy also clarified that reporting must be within 24 hours. Review of the 8/1/17 with CNA #1 on 8/22/17 at approximately 9:15 AM revealed that CNA #1 stated that s/he called the Director of Nursing (DON) when s/he witnessed Resident #15 inappropriately touching residents but waited until the DON returned to the facility to discuss it. Interview with DON on 8/22/17 at approximately 10:40 AM revealed that CNA #1 called while s/he was out of town but said her concern could wait until the DON returned. The DON also stated that CNA #1 did not discuss the suspected abuse until a week after the DON had returned. The DON clarified that both the administrator and unit manager were available for CNA #1 to report to. An initial 24-Hour Re… | 2020-09-01 |
| 1452 | 1452 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 582 | B | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to issue Advance Beneficiary Notice of Noncoverage (ABN) for two of two residents (Residents #94 and #255) discharged from Medicare Part A with benefit days remaining. The findings include: 1. Resident #94 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on 09/27/19. Although the resident was to be discharged from Medicare Part A with benefits days remaining, he would continue to be a resident in the facility. The facility did not issue an ABN. A second NOMNC was issued for services ending on 01/17/20. The resident was to be discharged from Medicare Part A with benefits days remaining, but he would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility. 2. Resident #255 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on [DATE]. Although the resident was to be discharged from Medicare Part A with benefits days remaining, she would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired F… | 2020-09-01 |
| 2815 | 2815 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-04-25 | 600 | G | 1 | 0 | IJ5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to keep residents free from abuse and neglect for 1 of 5 residents reviewed for abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. The findings included: Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of witness statements on 4/23/19 at approximately 10 AM revealed that Licensed Practical Nurse (LPN) #7 witnessed Resident #188 leaning forward from his/her wheelchair with his/her right hand extended inside the pants/thighs of Resident #45. Resident #188 moved his/her hand back and forth. When LPN #7 called Resident #188's name, the resident withdrew his/her hand and disappeared into his/her room. LPN #6 performed a body audit on Resident #45 and noted no perineal/vaginal trauma. Housekeeper #1 also witnessed Resident #188 with hand on private part of Resident #45. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees w… | 2020-09-01 |
| 1023 | 1023 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2017-09-21 | 514 | D | 1 | 1 | QQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain accurate information and have readily accessible documentation in the medical record for one of five residents reviewed for unnecessary medications. The medical record for Resident #5 contained inaccurate /conflicting information regarding admitted to hospice services. Information requested regarding monthly medication regimen review for resident #[AGE] was not provided as requested during survey. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of medical record on 9/20/17 at 9:00 AM revealed a telephone order initiated on 3/8/17 to Admit to Agape Hospice Diagnosis: [REDACTED]. Additional review of Order Summary Report Generated 8/30/17 revealed hospice admit order date of 3/8/2017. Further review of resident Census Report for Resident #5 identified a payer change to Medicaid/ Hospice on 2/1/17. During interview on 9/20/17 at approximately 11:45 AM, the Hospice Case Manager reported that Resident #5 was admitted to hospice services on 1/27/17. Additionally, s/he verified the hospice service start of care date was identified as 1/27/17 on the Hospice Certification of Terminal Illness form. When asked how hospice communicates with facility when a resident is admitted or discharged from hospice services, s/he replied, Once we have admitted , I write a telephone order to evaluate and admit to hospice if appropriate with the [DIAGNOSES REDACTED].#5 was admitted to hospice services on 1/27/17. When asked if she could locate the telephone order that was written to initiate hospice services, s/he replied that s/he would look for the telephone order and return. No further information was provided by the Hospice Case Manager related to a telephone order written on 1/27/17 to admit Resident #5 to hospice services. During interview with Business office manager on 9/21/17 at 4:35 PM, s/he verified that information for Resident #5 has an incor… | 2020-09-01 |
| 2184 | 2184 | ROCK HILL POST ACUTE CARE CENTER | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2019-11-22 | 881 | D | 1 | 1 | 9X3H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor for antibiotic use, antibiotic resistance patterns, and / or antibiotic outcomes per its Antibiotic Stewardship Program (ASP) policy. The findings included: Review of ASP policy on 11/20/19 at approximately 3:25 PM revealed the facility establishes a ASP team that monitors and summarizes antibiotic use from pharmacy data such as the rate of new starts, types of antibiotics used, or days of antibiotic treatment per 1,000 resident days. The ASP team, per policy, should also summarize antibiotic resistance patterns (e.g., antibiogram) as well as track measures of outcome surveillance related to antibiotic use (e.g., Clostridioides Difficile (C. diff), [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) or Carbapenem-resistant [MEDICATION NAME] (CRE)). Further, the ASP team should report on number of antibiotics prescribed and the number of residents treated each month. Interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/20/19 at approximately 3:45 PM revealed there was no monitoring of antibiotic use. Both pointed only to infection surveillance, which was primarily used to track transmissible infections both [MEDICAL CONDITION] and bacterial. Further, the DON and ADON were unable to produce documentation of monitoring for resistance patterns based on lab data, per their policy, or monitoring for potential outcome surveillance to antibiotic use. When asked about how the facility monitors / tracks residents who, for example, may contract [DIAGNOSES REDACTED] after a course of antibiotics, the DON and ADON were unable to answer. | 2020-09-01 |
| 207 | 207 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2019-11-27 | 641 | D | 1 | 0 | 4NC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to perform accurate fall assessments for 2 of 6 residents reviewed for accidents. Residents #7 and #13 had inaccurate fall assessments. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's fall assessments on 11/25/19 at approximately 1:26 PM revealed the following: 1. 8/30/19 assessment scored at 13. 2. 9/4/19 assessment - after his/her first fall in facility - scored at 3. Discrepancies were noted regarding medicines placing the resident at risk, alertness, and predisposing illnesses. Review of Resident #7's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's fall risk assessments on 11/25/19 at approximately 3:15 PM revealed the following: 1. 3/13/19 assessment scoring at 5. The resident was marked as alert with no predisposing illnesses or fall risk medications. This was inconsistent with other fall assessments. 2. 2/6/19 assessment scoring at 7. The resident was marked as alert with no predisposing illnesses. It should be noted that [MEDICAL CONDITION] is listed as a predisposing illness with regard to falls. Review of Resident #7's progress notes on 11/25/19 at approximately 3:25 PM revealed a 2/5/19 psychosocial note stating the resident was severely cognitively impaired related to a dementia diagnosis. Review of Resident #7's (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Administrator and Director of Nursing on 11/26/19 at approximately 3 PM confirmed the inaccurate assessments. | 2020-09-01 |
| 1482 | 1482 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2017-10-23 | 224 | D | 1 | 0 | M6T211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to prohibit misappropriation of medication intended for 1 of 3 reviewed for pain. Licensed [MEDICATION NAME] Nurse (LPN) #1 stole [MEDICATION NAME] 5 mg intended for Resident #3. The findings included: Review of LPN #1's statement on 10/23/17 at approximately 11:30 AM revealed LPN #1 took medication ([MEDICATION NAME] 5 mg) from Resident #3 and began a few months prior to confessing on 9/1/17. Review of the facility investigation summary on 10/23/17 at approximately 11:40 AM revealed that Resident #3's 30 tablets of [MEDICATION NAME] 5 mg appeared on a pharmacy receipt requisition document. Two days later the same resident's medication was written to have zero pills remaining, despite Resident #3 not receiving any as needed [MEDICATION NAME] 5 mg. The facility concluded the allegation of misappropriation of property was substantiated. Review LPN #1's statement on 10/23/17 at approximately 12:15 PM revealed LPN #1 resigned on 9/1/17 for taking medication from Resident #3. Interview with the administrator on 10/23/17 at approximately 2:40 PM revealed LPN #1 would take [MEDICATION NAME] and then zero out the card by forging a second nursing signature. This was only discovered when LPN #2 attempted to remove the [MEDICATION NAME] 5 mg because it had been discontinued. Interview with LPN #2 on 10/23/17 at approximately 3:40 PM revealed Resident #3's [MEDICATION NAME] 5 mg had been discontinued since the resident had not needed it for three months. LPN #2 attempted to remove it from the med cart and realized there was no medication in it. Since Resident #3 had been moved from Unit 1, LPN #2 asked Unit 1 if the medication had been discontinued and removed there. Upon learning that they had not done so, she alerted the administrator and the investigation began. Review of Controlled Drug Inventory Form on 10/23/17 at approximately 4:30 PM revealed that LPN #1 did zero out the medications of R… | 2020-09-01 |
| 3197 | 3197 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2019-12-04 | 641 | D | 1 | 1 | GRSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide accurate assessments for 1 of 40 residents on initial pool. Resident #2[AGE]'s Minimum Data Set (MDS) was inaccurate. The resident was marked as having a stage 4 pressure ulcer when s/he had none. The findings included: Resident #2[AGE] was admitted to the facility on [DATE]. Interview with family of Resident #2[AGE] on 12/2/19 at approximately 5:38 PM revealed the resident had a bed sore on arrival, though it had healed completely since then. Review of 11/9/19 quarterly MDS on 12/3/19 at approximately 11:08 AM revealed Resident #2[AGE] had been coded for a stage 4 pressure ulcer. Review of nursing notes on 12/3/19 at approximately 11:10 AM revealed a 9/22/19 note that the sacral wound had closed. Interview with Registered Nurse (RN) #3 on [DATE] at approximately 12:46 PM confirmed the miscoded MDS. RN #1 stated a trainee had filled out the MDS and had made a mistake. | 2020-09-01 |
| 268 | 268 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 684 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate quality of care for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6's head was injured during transfer, and neither Certified Nursing Assistant (CNA) reported it to nursing. The Director of Nursing (DON) agreed that they should have reported the incident as even a minor head injury could be serious in an elderly patient. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two CNAs entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not report to the nurse that night -- either that s/he had hit his/her head or that CNA #1 had cursed at him/her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. Staff interviewed CNAs #1 and #3. 10. Facility concluded that Resident #6 hitting his/her head against the wall was accidental. Abuse unsubstantiated. Review of CNA #3's statement on 10/22/19 at approximately 9:35 AM revealed the following: 1. CNA #3 was with CNA #1 during resident transfer from wheelchair to bed. 2. Resident #6 hit his/her head when staff placed his/her feet in t… | 2020-09-01 |
| 269 | 269 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 745 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate social services for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6 alleged staff of abuse, and when recounting abuse to the physician was tearful, but there was no follow-up social services or counseling for the resident. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two Certified Nursing Assistants (CNAs) entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not alert report to the nurse that night -- either that s/he had hit his/her head or that the CNA #1 had cursed at her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. RN #1 contacted agency regarding the incident and agency did not schedule CNA #1 pending completion of investigation. 10. Staff interviewed CNAs #1 and #3. 11. Social Service was to follow up and offer psychosocial support. 12. Resident was under APS custody due to living situation prior to admission to facility. 13. Facility concluded that Resident #6 hitting her head against the wall was accidental. Abuse unsubstantiated. Review of 5/6/19 p… | 2020-09-01 |
| 266 | 266 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 609 | E | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report abuse timely for Residents #1, #4, #5, and #6 (4 of 11 residents reviewed for abuse). Resident #1's misappropriation of property was not reported timely. Resident #5's sexual abuse allegation was not reported timely. Residents #6, #4, and #1 did not have 5-day reports submitted timely. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of 24-hour report and 5-day report on 10/21/19 at approximately 10:30 AM revealed the 5-day was reported 7 days later. Per the investigation summary, Certified Nursing Assistant (CNA) #4 was caring for Resident #4 when s/he passed gas. Per Resident #4, CNA #4 stated s/he better be glad it was just gas. Interview with Director of Nursing (DON) on 10/21/19 at approximately 11:51 AM revealed confirmed the 5-day report was late. The DON said several other 5-days of Facility Reported Incidents being investigated in the survey were late as well. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the Resident #6 accused CNA#1 of physical and mental abuse. The facility did not substantiated based on lack of evidence and inability to prove willful intent. Review of 5-day report on 10/22/19 at approximately 10:50 AM revealed the 5-day was submitted on 5/13/19, which was 7 days after the facility discovered the incident (5/16/19). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Facility Summary of Investigation on 10/22/19 at approximately 11:44 AM revealed Resident #1 accused Activities Assistant (AA) #1 of taking his/her money to buy him/her cigarettes. AA #1 shouted at resident that this did not occur and swore at the resident. Review of the 2/24 hour and 5-day report on 10/22/19 at approximately 12:21 PM revealed a delay in the 5-day report. The incident occurred on … | 2020-09-01 |
| 2890 | 2890 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 609 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report potential abuse for 2 of 12 residents reviewed for abuse. Resident #17 received an injury of unknown origin that was not reported to the state agency. Resident #24 made an allegation of abuse that was not reported to the state agencey. The findings included: Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of Resident #17's nurse's notes on 7/16/19 at 2:26 PM, revealed on 2/6/19 the nurse was called to the resident's room where a nurse aide was with the resident in the bathroom. The resident was tearful, complained of left upper arm pain and a purple/blue discoloration was observed on the resident's left, inner, upper arm. The note indicated the findings were reported to the Director of Nursing (DON) and nurse practitioner. Record review of Resident #17's progress notes from 2/6/19, on 7/16/19 at 3:10 PM, revealed the nurse practitioner evaluated the resident after receiving the report of the injury of unknown origin. The progress note also revealed the resident had tenderness, pain and limited ROM of the left arm. In addition the resid… | 2020-09-01 |
| 345 | 345 | CONDOR HEALTH ANDERSON | 425047 | 611 EAST HAMPTON STREET | ANDERSON | SC | 29624 | 2019-03-28 | 608 | D | 1 | 1 | HSS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report reasonable suspicion of a crime. Resident #75 accused Resident #68 of sexual abuse, and the facility failed to report the allegation to the police for investigation. The findings included: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent score for Brief Interview of Mental Status (BIMS) was 13. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent BIMS score was 6. Review of the 24 Hour and 5 Day report on 3/27/19 at 1:51 PM revealed Resident #75 alleged Resident #68 had been messing with his/her genitals a few days before 11/1/18. There were no witnesses. Interview with Social Services Director #1 on 3/27/19 at 4:18 PM revealed that the allegation was not reported to the police. Interview with Resident #75 on 3/27/19 at 3:25 PM revealed s/he maintained the allegation that Resident #68 was messing with (him/her) in her room at night and it had been unwitnessed. S/he was unable to offer further details such as what resident #68 had done or when it occurred. Review of abuse policy on 3/28/19 at 11:59 AM revealed that in response to allegations of sexual abuse the facility is to immediately report the allegation to the administrator, the physician, the appropriate state and local authorities. | 2020-09-01 |
| 267 | 267 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 610 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to sufficiently investigate abuse for Resident #4 (1 of 11 residents reviewed for abuse). The facility failed to obtain a proper statement from an Certified Nursing Assistant (CNA) #4. Because the statement taken by the Director of Nursing (DON) was neither signed by the CNA nor witnessed by a third party, and because the CNA later denied making that statement, the abuse could not be substantiated. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of DON's recollection of CNA #4's statement on 10/21/19 at approximately 10:45 AM revealed the following: 1. CNA #4 confirmed s/he stated the resident better be glad it was just gas. 2. CNA #4 stated s/he thinks the resident sprays them with poop on purpose. S/he thinks s/he gets off on getting his/her poop on employees. 4. CNA #4 did not sign this statement. It was written and signed by the DON. There were no witness signatures. Interview with CNA #4 on 10/21/19 at approximately 1:55 PM revealed the following: 1. CNA stated s/he only asked the resident to inform him/her if s/he felt the urge to pass gas. 2. Resident #4 passed gas. CNA #4 denied saying anything to making threats. 3. When asked about his/her statement, CNA #4 denied writing a statement. S/he spoke with staff regarding what happened, but s/he did not see what they wrote. S/he was concerned they misunderstood what s/he said, as s/he did express that s/he was glad (Resident #4) only passed gas to other staff members. Interview with DON on 10/21/19 at approximately 2:10 PM revealed there was no signed statement from alleged perpetrator. DON confirmed there was no third-party witness who could corroborate what CNA #4 told him/her following the incident. S/he stated CNA #4 was fuming and upset following the incident and complained about the resident, saying s/he got off on getting feces on staff. The DON immediately escorted CNA #4 out of … | 2020-09-01 |
| 337 | 337 | GREENVILLE POST ACUTE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2019-10-17 | 689 | D | 1 | 0 | F9YN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to take reasonable steps to prevent accidents for 2 of 10 residents reviewed for abuse. On 12/10/18 Certified Nursing Assistant (CNA) #1 was pushing Resident #1 in a wheelchair. When the resident lowered his/her feet onto the floor, the CNA continued pushing the resident, directly contributing to the resident's fall. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 12/10/18 incident report on 10/16/19 at approximately 9:25 AM revealed the following. 1. Nurse was near nursing station med cart when she witnessed staff member pushing patient in wheelchair. Resident #1 tried to stop the chair with his feet which caused patient to fall out of chair. 2. Resident was transferred off the floor to the wheelchair with help of another staff member. 3. Vitals were obtained and skin assessment performed. There were no visible injuries observed. Review of CNA #1's statement on 10/16/19 at approximately 9:33 AM revealed the following: 1. CNA #1 was pushing Resident #1 in wheelchair. Resident put both his feet on the floor while she was pushing, slowing the wheelchair down. 2. CNA #1 continued to push the wheelchair. 3. The resident thought s/he had stopped and tried to stand while wheelchair was still in motion, falling to the floor. Review of Registered Nurse (RN) #2's statement on 10/16/19 at approximately 9:37 AM revealed the following: 1. RN #2 was near the medcart. S/he observed CNA #1 pushing Resident #1 in the wheelchair. 2. While approaching room [ROOM NUMBER], the resident tried to get out of the chair. CNA #1 told the resident to pick up his/her feet but continued pushing the chair. 3. Resident #1 fell to the floor next to the 100 room. 4. RN #2 reprimanded CNA #1, explaining the fall could have been prevented and would be reported. 5. Vitals were taken and Resident #1 was assessed. S/he was found to be without injury. Intervie… | 2020-09-01 |
| 276 | 276 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-12-20 | 607 | D | 1 | 0 | 0G2K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of facility Leadership Policies and Procedures for Abuse Neglect, Exploitation, or Mistreatment, the facility failed to implement its policy related to investigations for abuse for 2 of 3 reviewed for abuse related to injury. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the facility's investigation of a fall for Resident #7 on 10/14/18 at 11:30 AM revealed an account of the incident written by the Administrator. Only 2 witnesses were listed . During an interview with the Administrator on 12/20/18 at 8:30 AM, he/she confirmed that he/she did not get a written witness statement from either of the two witnesses involved. He/she also confirmed that no statements were obtained from the other staff working on the unit at the time of the incident. There was also no interview statement from the resident who was interviewable. Review of the facility Leadership Policies and Procedures for Abuse, Neglect, Exploitation, or Mistreatment under Component VI: Investigation: #5 Written summaries of individuals having first hand knowledge of the incident. Designated facility staff will interview the staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. No document was submitted by the Administrator or facility staff. The Administrator thought he/she had done interviews but could not find the documentation. Resident #102 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/20/2018 at 3:00 PM, Resident #102 was noted during wound care to have bruising to her left foot, 5th toe. On X-ray the resident was noted with an acute [MEDICAL CONDITION] metatarsal neck. The resident was not ambulatory and transferred by Hoyer Lift. Resident #102 was unable to recall any injury to his/her foot. After interviewing the staff and resident, the facility was unable to determine how the fra… | 2020-09-01 |
| 4002 | 4002 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 550 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility documents, the facility failed to ensure one (1) of 20 sampled residents was provided dignity in the provision of services. Resident #61 requested not to be provided care by Certified Nursing Aide (CNA) #8. Responsible nursing staff did not provide follow-up to determine the cause of Resident #61's request. CNA #8 continued to enter Resident #61's room against the resident's request. The findings included: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to receive care from the center in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality .You have the right to reside and receive care in the center with reasonable accommodations of individual needs and preferences except when your health and safety or the health and safety of other patients/residents would be endangered .You have the right to receive care, treatment and services that are adequate and appropriate and provided: d. With respect for your personal dignity and privacy. Resident #61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had mild symptoms of depression and had no documented behavioral symptoms. Resident #61 require extensive assistive of one (1) staff person for bed mobility, dressing, toileting and personal hygiene. Resident #61 was always incontinent of bowel and bladder. Review of The Care Area Assessment (CAA) of the MDS revealed behavioral symptoms were not triggered and not moved forward to the comprehensive care plan. Review of Resident #61's Self-Care Deficit/Activities of Daily Living (ADL) care plan dated [DATE] revealed the resident had a self-care deficit due to impaired mobility and function… | 2020-09-01 |
| 4008 | 4008 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 692 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility policy, the facility failed to initiate approaches to prevent further weight loss for one (1) of 20 sampled residents (Resident #66). Resident #66 had a 4.4% weight loss in 10 days and the Nurse Practitioner and Registered Dietician recommendations to address the weight loss were not initiated. The findings were: Review of the facility's Weight Monitoring Program last revised 6/13/18 noted residents who experience significant weight loss will be weighed weekly and reviewed weekly for a minimum of four (4) weeks until weight is stable or increasing .A significant weight change is identified as: 5% weight loss or gain in one month; 7.5% weight loss or gain in three months; and 10% weight loss or gain in six months .All disciplines should be aware of all patients/residents who are on a weight monitoring program. Resident #66 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired and required total assistance of staff for eating. According to the assessment the resident was 58 inches in height and weighed 112 pounds (lbs), during the assessment period. Review of Resident #66's Nutrition care plan dated [DATE], Resident #66 was at risk for decline in nutritional status related to increased nutrient needs for wound healing, dependent on staff for feeding, has poor appetite and low [MEDICATION NAME] with [DIAGNOSES REDACTED]. Approaches - follow colored napkin protocol; provide supplements as ordered; provide diet as ordered; ST (speech therapy) to evaluate and treat per physician's (MD) order; weigh and observe result, notify MD/IDT (interdisciplinary team) of significant weight changes. Review of Resident #66's History & Physical (H&P) dated 9/18/19 noted that the resident entered the facility with severe protein malnutrition. Review o… | 2020-09-01 |
| 2631 | 2631 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2019-12-12 | 600 | D | 1 | 0 | YLVU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review, and facility policy review, the facility failed to ensure four (4) of 34 sampled residents (Residents #7, Resident #8, Resident #9, and Resident #10) were free of sexual abuse. Resident #7 sexually assaulted Resident #8 while she slept in her wheelchair. Resident #10 was found sexually assaulting Resident #9. The facility did not assess the residents' capacity to consent to sexual activity. The findings included: Review of facility Abuse Prevention policy revised August 2019 revealed Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation, as well as misappropriation of resident property, are prohibited. 1. Review of Resident #7's face sheet dated 12/12/19 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE], prior to the incident, indicated he was understood by others and usually understood others. The assessment indicated he had no impairment to his cognition with a Brief Interview of Mental Status (BI[CONDITION]) score of 14 out of 15. The assessment did not indicate he had any negative behaviors towards others in the past 14 days. Review of Resident #7's comprehensive care plan revised 6/25/18 revealed Resident #7 had a history of [REDACTED]. Interventions included to have the resident on one to one monitoring (tapered off 7/3/18), resident to be placed on Behavior Management Program, for staff to help him understand why the behavior was inappropriate, a psychiatric consult as ordered. Review of Resident #8's face sheet dated 12/12/19 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's MDS dated [DATE], prior to the incident, indicated she was usually understood and sometimes understands others. She was assessed as having impaired cognition (BI[CONDITION] score of 3 ou… | 2020-09-01 |
| 2632 | 2632 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2019-12-12 | 607 | E | 1 | 0 | YLVU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review, and review of facility policy, the facility did not ensure the Abuse Prohibition and Abuse Investigation Policy contained required information regarding investigating sexual abuse for 4 of 6 residents (Residents #7, #8, #9, and #10) reviewed for sexual abuse allegations. Resident #7 sexually assaulted Resident #8, and Resident #9 and #10 were engaged in sexual activity. The facility abuse policy did not contain information how to investigate each resident's capacity to consent to sexual activity. The findings included: Review of the facility Abuse Prohibition policy and the facility Abuse Investigations policy, both revised August 2019, revealed there was no information related to investigating a resident's capacity to consent to sexual activity in a resident to resident alleged sexual abuse incident. Review of facility incident dated 8/23/18 revealed CNAs #4 and #12 witnessed Resident #7 wheel up to Resident #8, who was in her wheelchair in the television area. CNAs #4 and #12 witnessed Resident #7 stroke Resident #8's thigh and groin area. CNA #12 wrote in her statement that Resident #7 was patting between his legs and saying he wanted some (name for female genitalia). Review of facility incident dated 3/13/19 revealed on 3/8/19, RN #1 heard a chair alarm and call bell going off in Resident #9's room. When RN #1 entered the room, she found Resident #9 and Resident #10 engaged in sexual activity. The facility investigation determined the incident was substantiated and did occur. In an interview on 12/11/19 at 5:06 p.m., the administrator stated there was no formal written policy to determine the capacity for a resident to consent to sexual activity, whether they had cognitive impairment or not. Review of Centers for Medicare and Medicaid Services State Operations Manual Appendix PP F[AGE]0, revised 11/22/17, revealed When investigating an allegation of sexual abuse, the facility must conduct a th… | 2020-09-01 |
| 2593 | 2593 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2019-12-15 | 578 | D | 1 | 1 | WN1111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review, the facility failed to ensure information on formulating an Advanced Directive was discussed with a resident. This affected one out of two sampled residents reviewed for Advanced Directives (Resident #49). The findings included: Review of the clinical record revealed an admission history form dated [DATE]. The admission history documented Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] documented that the resident had no memory impairment. On [DATE] at 3:06 PM, Resident #49's medical record was reviewed. An Advanced Directive could not be located within the medical record. Resident #49's code status could not be located within her medical record. On [DATE] at 11:41 AM, the Nursing Home Administrator (NHA) was interviewed. She stated, we have advanced directive information in the admission packet. Staff are available to assist if someone wants advanced directive information. The resident or their responsible party would be referred to Social Services. If we are notified by admissions, we would give the paperwork for the advanced directives. The admission coordinator asks if there was a living will or healthcare power of attorney. If there was one, we would ask for a copy to be brought in and placed in the medical record. If there isn't one, but they would like more information, we refer them over to Social Services. The admission's coordinator doesn't have any document that is filled out to show they asked besides the signed acknowledgement form that the resident received the admission packet. The admission packet explains about living wills and healthcare power of attorney. On [DATE] at 3:05 PM, Resident #49 was interviewed. Resident #49 stated that she's been at the facility for 3 years and the only thing that they had asked her was if she wanted chest compressions/CPR. She was not aware that she could make h… | 2020-09-01 |
| 301 | 301 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2017-05-11 | 282 | E | 1 | 1 | X7DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review the facility failed to follow the care plan for 1 of 5 residents reviewed for unnecessary medications, 2 of 4 reviewed for pressure ulcers, and 2 of 6 residents randomly reviewed for transfers. Resident #70's care plan was not followed with regards to blood sugar, blood pressure, and constipation. Resident #70 and Resident #113 were not positioned as care planned. Residents #101 and #118 were not transferred per care plan. The findings included: Review of transfer assessment for Resident #101 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a medium-sized sling assisted by 2 caregivers. Review of the transfer assessment for Resident #118 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a small-sized sling assisted by 2 caregivers. Interview with Certified Nursing Assistant (CNA) #3 on 5/11/17 at approximately 10:22 AM revealed that s/he used a large-sized sling when transferring resident #101. When asked if s/he needed to consult the CNA Care Sheet, s/he said no because s/he knew. The CNA stated Resident #101 had gained weight, and the CNA had been using a large-sized sling during transfer to compensate. S/he continued that s/he had not alerted a nurse that the resident may require reassessment. The CNA left during the interview, and s/he returned to state that s/he was mistaken and had only used a large-sized sling once. Interview with CNA #3 on 5/11/17 at approximately 10:22 AM revealed that the CNA did not use a sling or lift to transfer Resident #118 because the resident can pivot weight. When asked about the assessment stating the resident required a lift with a small sling and 2 caregivers for transfer, the CNA stated that the resident was incorrectly assessed and that it depended on her days. Review of Care Plan for Resident #118 on 5/11/17 at approximately 10:30 AM revealed that the resident … | 2020-09-01 |
| 1130 | 1130 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 656 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, policy review, and medical record review, it was determined the facility failed to ensure that the care plan was followed for 1 of 19 sampled residents (Resident #16). On [DATE] Certified Nurse Aide (CNA) #3 and CNA #4 transported Resident #16 back to his/her room. CNA #3 and CNA #4 stated although Resident #16 was a mechanical lift for transfer, they transferred Resident #16 back to bed without using a mechanical lift by supporting Resident #16's legs and back. Findings include: The Face Sheet, located in the Electronic Medical Record (EMR) stated Resident #16 was admitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. An The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR stated Resident #16 had significant cognitive impairment and had not been transferred out of bed. Review of the Nurse Aide's Information Sheet that was undated, located in the EMR stated Resident #16 was confused and required a mechanical lift with two persons for transfer. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 12:30 PM, he/she stated a mechanical lift was to be used for residents who were not able to weight bear. The ADON stated Resident #16 was not able to weight bear and a mechanical lift and two staff were to be used for any transfers. The ADON stated Resident #16 was rarely out of bed. The Safe Lifting and Handling of Residents policy, dated July 2019, stated that staff lifting of residents shall be eliminated when feasible. A lift assessment should be completed on admission, quarterly, and annually, or with significant change. The Nursing Lift Evaluation Form, dated 11/4/19, located in the EMR stated Resident #16 was non weight bearing and was a full lift transfer. During an interview with CNA #1 on [DATE] at 2:30 PM and with CNA #2 on [DATE] at 9:28 AM, they stated prior to [DATE], Resident #16 had not requested they transfer him/her out of bed. CN… | 2020-09-01 |
| 1131 | 1131 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 657 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and policy review it was determined the facility failed to revise care plan interventions for 1 of 19 sampled residents, (Resident #5). Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet, located under the Profile tab of his/her Electronic Medical Record (EMR) revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located in the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #5's Interdisciplinary Team (IDT) progress notes, located under the Prog Notes tab of the EMR, revealed Resident #5 was discovered engaging in a sexual activity with another resident on 10/14/19 at 7:41 PM. Further review of the IDT notes revealed the residents were separated, the police were called, and the residents were prohibited from visiting privately the rest of the evening. Review of Resident #5's clinical record revealed a Death in Facility Tracking Record which documented she passed away on [DATE], thus was unavailable for observation or interview during the survey. An interview with the Social Services Director (SSD) on 01/14/19 at 10:45 AM revealed he/she had been informed that it was Resident #5's right… | 2020-09-01 |
| 2816 | 2816 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-04-25 | 607 | G | 1 | 1 | IJ5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment the facility failed to implement the facility policy to keep residents free from abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. Additionally, the facility failed to report abuse to the state agency and investigate incidents dated 1/2/19 and 2/3/19 involving Resident #188. The facility failed to report incidents of sexual abuse dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 to Law Enforcement. The facility failed to investigate abuse, Resident #187 made an allegation of abuse and the facility failed to interview the staff members involved or who had knowledge of the allegations. 2 of 5 residents reviewed for abuse The findings included: Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursin… | 2020-09-01 |
| 4005 | 4005 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 677 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy, it was determined the facility failed to provide the necessary services to provide and/or maintain activities of daily living (ADLs) related to personal hygiene and/or bathing for three (3) of 20 sampled residents (Residents #26, #34 and #68). Resident #26 requested but did not receive a shower between August 2019 and January 1, 2020. The resident was provided bed baths only. Resident #34 was assessed as extensive assistance with one (1) person for personal hygiene; however, staff failed to provide weekly showers as scheduled on Tuesday, Thursday and Saturdays. Resident #34 had not had a documented shower since 11/12/19 during the day shift. Resident #68 did not receive assistance with nail care when the resident's nails were long and jagged. The findings include: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to: c. Make choices about aspects of your life in the nursing center that are significant to you. Review of a policy entitled Documentation: Charting Activities of Daily Living (ADLs) (reviewed 10/24/18) revealed a policy statement that it is required for ADL care given by Certified Nursing Assistants (CNAs) and nurses to be documented using the CNA ADL Flow Sheet Form. For facilities with smart charting, all documentation will be completed using the smart charting system. During interview on 1/16/2020 at 3:47 PM, the Director of Health Services (DHS) stated the facility did not have a policy for bathing a dependent resident. Resident #26 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of Resident #26's annual Minimum Data Set (MDS) Assessment, dated [DATE] revealed a brief interview for mental status score of 13, indicating the resident was independent in cognitive skills for daily decision making. Resident #26 was identified on the assessment to have no sy… | 2020-09-01 |
| 1065 | 1065 | SUMTER EAST HEALTH & REHABILITATION CENTER | 425107 | 880 CAROLINA AVENUE | SUMTER | SC | 29150 | 2017-05-06 | 247 | D | 1 | 1 | G1PJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility's policy entitled Room and Roommate Assignment, the facility failed to provide prior notice of a change in roommate for 1 of 1 resident reviewed for Admission, Transfer and Discharge. The findings included: The facility admitted Resident #136. During an interview on 04/07/17, Resident #136 stated after returning from [MEDICAL TREATMENT] s/he learned s/he had a new roommate. In a follow up interview, the Admissions Director revealed that Resident #136 had two roommate changes on (MONTH) 10th and 25th of (YEAR). Review of the Social Services Notes on 04/07/17 revealed there was no evidence of notification of Resident #136 or the responsible party In a subsequent interview, the Director of Social Services stated that Resident #136 was not notified because the new roommates were new admissions. Review of the facility's policy entitled Room and Roommate Assignment, revealed that when there is a change all parties involved will be provided with a 48-hour advance notice of the change whenever possible. | 2020-09-01 |
| 2196 | 2196 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2019-11-14 | 610 | D | 1 | 0 | NVCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation for one (1) resident who made an allegation of sexual abuse (Resident #1). The findings included: Review of the facility's undated Abuse Policy: documented the following: Protection Abuse Policy .The progress notes, concerning all residents involved, should include: 6. What was done to prevent further harm to resident or others. Documentation will continue over 72 hours. An acute care plan will be developed that identifies methods for prevention of further occurrence .In House Investigation .Steps taken to protect the alleged victim from further abuse, particularly when an alleged perpetrator has not been identified. Actions taken as a result of the investigation, to include corrective action taken .Abuse Prevention Program, Community Procedures VI. 4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents .7. Final Abuse Investigation Report .The final investigation report shall contain the following .Facts determined during the process of the investigation, review of medical record and interview of witnesses . Conclusion of the investigation based on known facts .Attach a summary of all interviews conducted .VIII. External Reporting of Potential Abuse. 1 .Steps the community has taken to protect the resident. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating moderate cognitive impairment. The MDS recorded the resident had minimal hearing difficulty, clear speech… | 2020-09-01 |
| 2652 | 2652 | PRINCE GEORGE HEALTHCARE CENTER | 425295 | 901 MAPLE STREET | GEORGETOWN | SC | 29440 | 2020-01-03 | 550 | D | 1 | 0 | XVX011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of facility policy, the facility failed to ensure dignity was provided to 1 of 1 resident reviewed for quality of care (Resident #340). The findings included: Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/13/2019, the facility was notified that Resident #340 had arrived to their [MEDICAL TREATMENT] appointment only wearing a shirt and a brief. Record review on 1/2/2020 at 3:57 PM revealed Resident #340 had a Brief Interview of Mental Status (BI[CONDITION]) score of 4, indicating s/he was cognitively impaired. S/he was extensive assistance to total dependence with activities of daily living (ADLs). Review of the medical record shows a Physician order [REDACTED].>During an interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 1:51 PM, s/he stated The night shift washed the resident off and got them situated. When transport picked them up, s/he was in another room and did not get a chance to double back and finish getting them dressed. Transport sometimes comes early, but will ask if the resident is ready prior to taking them. Since the resident is tube-fed, the nurse has to disconnect it prior to them leaving. Since the nurse had to disconnect it prior to them going, it should have been noted that the resident was not properly dressed. When asked by the surveyor if it would have been realized that the resident was not dressed at any other time prior to leaving the facility, the CNA confirmed that it would have been noticeable, although a sheet was in place. The facility was unable to provide a policy related to dignity, but did provide a list of residents' rights. During an interview with the Director of Nursing on [DATE] at 1:30 PM, s/he stated it is the facility's expectation that when residents leave to go to outside appointments that they are properly dressed. Per the facility's policy titled, Self Determination reviewed on [DATE] at 2:15 PM, … | 2020-09-01 |
| 143 | 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects re… | 2020-09-01 |
| 2198 | 2198 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 607 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policy by failing to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner, failed to place potential perpetrators on leave during investigations, failed to ensure residents were interviewed during the course of the investigations, and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 resident's residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 01/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated, They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to reside… | 2020-09-01 |
| 2296 | 2296 | CARLYLE SENIOR CARE OF FOUNTAIN INN | 425168 | 501 GULLIVER ST | FOUNTAIN INN | SC | 29644 | 2019-05-09 | 610 | D | 1 | 1 | LM2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to ensure all allegations of abuse and neglect were thoroughly investigated for three of ten sampled residents reviewed for Facility Reported Incidents (FRIs) (Resident (R) 151, R152, and R25 . Review of the FRI's revealed during the course of the investigations, the facility failed to ensure other residents and staff not involved in the allegations but may have had information related to the allegations were interviewed per the facility's policy. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 07/14/17, specifically section 7. Investigation of Alleged Abuse, Neglect, and Exploitation, revealed when reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Continued review of the policy revealed once the resident was cared for and initial reporting has occurred, an investigation should be conducted. Further review of the policy revealed components of an investigation may include: a. Interview the involved resident, if possible, and document all responses and if the resident is cognitively impaired, interview the resident several times to compare responses; b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident; c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements according to appropriate policies. All statements should be signed and dated by the person making the statement. 1.Review of R151's Face Sheet, located in the front of the resident's c… | 2020-09-01 |
| 3544 | 3544 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 610 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to ensure all allegations of neglect and resident to resident abuse were thoroughly investigated for two of 11 sampled residents reviewed for Facility Reported Incident's (FRI's) (Resident (R) 99 and R43). On 01/22/19 the facility initiated an investigation for an allegation of neglect related to R99, which concluded on 01/25/19; however, when reviewing the investigation, the facility failed to ensure all components of the complaint were investigated. Additionally, during an investigation related to resident to resident abuse involving R43, the facility failed to interview a cognitively intact resident who witnessed the incident. Findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised (MONTH) (YEAR), revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Continued review of the policy revealed. the individual conducting the investigation will, as a minimum: .d. interview any witnesses to the incident; .g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. 1. Review of R99's, Face Sheet, located in the front of the resident's paper chart, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Initial 24-hour Report, dated 01/22/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse. Continued review of the report revealed the RR (resident representative) made allegation of neglect. Investigation initiated immediately. Full report t… | 2020-09-01 |
| 3543 | 3543 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 607 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to implement their Abuse Prevention Program policy and ensured employees identified and reported an allegation of neglect to the facility's administrator immediately for one of 11 sampled residents reviewed for Facility Reported Incident's (FRI's) (Resident (R) 99). On 01/22/19, the facility reported an allegation of neglect to the state agency and initiated an internal investigation. During the review of the facility's investigation and interviews, it was determined R99's son/daughter reported the incident to a facility Registered Nurse (RN); however, the RN failed to identify the reported incident as an allegation of neglect and failed to report the allegation immediately to the facility's Administrator. Findings include: Review of the facility's policy titled, Abuse Prevention Program, revised (MONTH) (YEAR), revealed as part of the resident abuse prevention, the administration would: 3. Develop and implement policies and procedures to aid in the facility preventing abuse, neglect, or mistreatment of [REDACTED]. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior, and .6. Identify and assess all possible incidents of abuse. Review of R99's, Face Sheet, located in the front of the resident's paper chart, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R99's Annual Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) under the MDS tab, dated 04/10/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed the res… | 2020-09-01 |
| 2 | 2 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 610 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to ensure all allegations of abuse and injury of unknown sources were thoroughly investigated for four of 14 sampled residents reviewed for facility reported incidents (FRI's) (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to interview other residents of the facility. On 12/02/18 a sewing needle was discovered in R4's wound on top of her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to initiate an investigation. On 01/08/19 R1, who was not cognitively intact, experienced what the facility identified as an injury of unknown source; however, it was not thoroughly investigated. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to conduct a thorough investigation. Findings include: Review of R9's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS) completed on 11/05/18 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM. Review of the facility's Five-Day Follow-Up Report, dated 11/5/18, revealed Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 1 were the only staff interviewed about the incident. Additionally, there was no documented evidence interviewable residents in the facility… | 2020-09-01 |
| 1 | 1 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 609 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to report an allegation of abuse and injury of unknown source within the required time frame to the appropriate state agency as required for four of 14 sampled residents (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to report the allegation of verbal abuse to the state agency within the required two-hour time frame. On 12/02/18 a sewing needle was discovered in R4's wound on top of his/her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to report it to the state agency. On 01/08/19 R1 who was not cognitively intact experienced what the facility identified as an injury of unknown source; however, it was not reported to the state agency until 01/10/19 two days after the fact. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to report the misappropriation of the resident's medication within the required two-hour time frame to the state agency. Findings include: Review of R4's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18, revealed the facility assessed the resident to have a BIMS score of four out of fifteen, indicating the resident was severely cognitively impaired. During an interview on 01/20/19 at approximately 2:35 PM, the facility's Risk Manager (RM) revealed the incident of the sewing needle being discovered in R4's wound on her/his foot was not reported to the state agency as an injury of unknown source. The RM stated the resident could not tell how the needle got into the wound and it was not witnessed either. During an i… | 2020-09-01 |
| 3269 | 3269 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2018-08-21 | 839 | D | 1 | 0 | CMHW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and facility files, the facility failed to prevent an unqualified staff member from providing phlebotomy services for 1 of 1 residents reviewed for blood draw. Resident #3 had blood drawn from a Certified Nursing Assistant (CNA). The findings included: In response to an initial reportable incident received in this office an investigation was conducted at the facility. Per the facility report, a Registered Nurse (RN) allowed a Certified Nursing Assistant to draw blood on a resident, resident #3. The facility investigation included statements given by the RN and the CNA. Both the RN and CNA confirmed the CNA had drawn blood on the resident. The CNA said s/he was a phlebotomist at the hospital. The RN stated s/he was not aware the CNA could not draw blood in the long term care setting. The RN and the CNA were placed on suspension pending the investigation. On [DATE] at 1:09 PM, the surveyor interviewed the Director of Nursing (DON). A nurse called me yesterday and asked me to look into it. S/he said s/he was told that a CNA had drawn labs on a resident. The CNA works part time and draws labs at the hospital. The nurse knew s/he was a phlebotomist at the hospital. The nurse was here yesterday that had worked the weekend. I asked her/him about labs being drawn on the weekend. I asked if s/he had drawn labs. The RN stated s/he had drawn the labs but the CNA was right there with her/him. I told the nurse I had already talked to the CNA. S/he then retracted it, and said the CNA drew the labs but the RN was right there. S/he said it was only the one resident. I asked where s/he was at the time and s/he said s/he was at the door within direct sight of the CNA. I told the nurse and the CNA that a CNA could not draw blood here at the facility, it was beyond their scope of practice. The DON had not seen a certification on phlebotomy for the CNA. At 2:40 PM the CNA was interviewed per phone by the surveyor. I am a PCT (Patient Care Te… | 2020-09-01 |
| 402 | 402 | BLUE RIDGE IN GEORGETOWN | 425048 | 2715 SOUTH ISLAND ROAD | GEORGETOWN | SC | 29440 | 2018-11-17 | 550 | D | 1 | 0 | H6ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident #4 was treated with respect and dignity during activities of daily living. 1 of 3 sampled residents for dignity. Resident #4 stated that Certified Nursing Aide (CNA) #1 left her/him uncovered for thirty minutes during incontinent care. The findings included: The facility admitted Resident #4 on 2/17/16 with [DIAGNOSES REDACTED]. Review of Resident #4's electronic medical record on 11/04/18 at approximately 12:44 PM revealed a quarterly Minimum Data Set ((MDS) dated [DATE] that indicated Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14. The resident was listed on the interviewable list provided by the facility during the survey. During an interview with Resident #4 on 10/03/18 at approximately 10:45 AM. Resident #4 stated that when he/she was evacuated to another facility, CNA #1 provided incontinent care and left the bed covers pulled up from his/her feet to his/her waist for about thirty minutes until the CNA returned and provided care. During an interview with CNA #1 on 11/04/18 at approximately 8:45 AM. CNA #1 confirmed he/she did leave Resident #4 uncovered for approximately 15 to 20 minutes. | 2020-09-01 |
| 239 | 239 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2019-10-20 | 609 | D | 1 | 1 | 4IGP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to report allegations of abuse and bruises of unknown origin to the appropriate agencies within the required time frames for two of five residents reviewed for allegations of abuse (Resident #11 and Resident #94). Findings include: 1. Resident #11 According to the Face Sheet, Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 07/14/19, Resident #11 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine out of 15. She required total assistance with all activities of daily living (ADL). The reportable incident investigation and letter were reviewed. The letter was sent to the state agency on 08/16/19. The letter served as the initial and final notification of the reportable incident. The reportable incident was that a Certified Nurse Aide (CNA) had repeatedly bashed Resident #77's head against the nightstand and twisted her arm on 08/09/19. Through the investigation, it was determined the incident occurred on 08/08/19 and not 08/09/19. Three CNA statements were obtained on 08/15/19. CNA #31 was interviewed on 10/18/19 at 5:39 PM. She was the CNA working with Resident #11 the evening of 08/08/19. She said when dinner trays were being passed, it was announced that bingo was going to be starting. Resident #11 requested to go. CNA #31 told her that she could not get her up right then because she needed to finish passing trays and assist with feeding residents. She said Resident #11 was very upset and took her reacher and hit the end of the bed. The following day, on 08/09/19, Resident #11 had a bruise on her arm, so she was questioned about it. She said charge Nurse #9 and Social Worker #108 completed the investigation. Resident #11 informed them that CNA #31 had banged her head against the bedside table and she grabbed her arm. She said she did neither of… | 2020-09-01 |
| 1445 | 1445 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 602 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of facility files, the facility failed to safeguard resident financial accounts against misappropriation for 11 of 21 resident accounts. The findings included: Cross refer to F567, F568, F569 related to resident funds. Review of the facility investigation of allegations of misappropriation of resident financial accounts revealed the facility stated 21 resident accounts were involved. Then it stated there were 11 resident accounts affected. Their investigation showed six (6) residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident who deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. The facility did not provide the total amount of monies involved, only the amount of money reimbursed. The District Director stated that only the residents that could confirm there was a problem with their accounts were reimbursed. On [DATE] at approximately 9:30 AM, the facility's Business Office Manager was interviewed by the surveyor. I was just hired in June. Things didn't look right, so I started doing an audit and things were not right. I sent the information of the audit to my boss at corporate and they took over the investigation. The final audit has not been completed yet, only the in-house residents. discharged resident accounts have not had a completed audit yet. The previous Business Office Director (BOD) was just arrested last night. At this time the amount is over $50,000.00. At Approximately 12:30 PM, the corporate representative, District Director of Business Office Services, was interviewed by the surve… | 2020-09-01 |
| 1441 | 1441 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 567 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of facility files, the facility failed to safeguard resident financial accounts for 11 of 21 resident accounts. The findings included: The facility reported to the state agency an allegation of misappropriation on [DATE]. A visit was made to the facility to investigate the allegations. At the time of the investigation on [DATE] the facility did not have the documentation of the investigation at the facility. During the Entrance Conference, the Administrator informed the surveyor, s/he had only been at the facility for approximately three (3) weeks and the Corporate Office handled the investigation. The Administrator was aware of the incident but did not know the specifics. The facility at one point stated that 21 resident accounts were involved. Then it stated there were 11 resident accounts affected. Their investigation showed only six residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident who deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. On [DATE] at approximately 9:30 AM, the facility's Business Office Manager was interviewed by the surveyor. I was just hired in June. Things didn't look right, so I started doing an audit and things were not right. I sent the information of the audit to my boss at corporate and they took over the investigation. The final audit has not been completed yet, only the in-house residents. discharged resident accounts have not had a completed audit yet. The previous Business Office Director (BOD) was just arrested last night. At this time the amount is over $50,00… | 2020-09-01 |
| 651 | 651 | WHITE OAK MANOR - NEWBERRY | 425077 | 2555 KINARD STREET | NEWBERRY | SC | 29108 | 2019-12-12 | 842 | D | 1 | 1 | 5CPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observation, and record review, the facility failed to ensure that clinical paper and electronic records were complete and accurate for 1 of 25 sampled resident reviewed. Resident #87 had no dietary/nutritional notes in his/her medical record. The findings included: The facility admitted Resident #87 on 7/30/19 with [DIAGNOSES REDACTED]. During individual interview on 12/10/19 at approximately 9:55 AM Resident #87 stated he/she would like a variety of foods in his/her diet. When asked if anyone has specifically addressed his/her diet the resident stated he/she would like to talk to someone about his/her diet. A review of the electronic medical record on 12/11/19 at approximately 1:07 PM revealed the resident was on a regular renal diet with no fluid restrictions noted. A meal delivery observation on 12/11/19 at 1:18 PM revealed Resident #87 received diet as ordered. Staff had to encourage the resident to wake up to eat. Staff placed the food tray on the bedside table and raised the resident's bed. A review of the medical record on 12/11/19 at 2:40 PM revealed no dietary/nutritional notes in paper or electronic medical records. The paper chart had multiple yellow sheets indicating diet changes with no accompanying notes or dietary consults/assessments. The facility staff could not locate any dietary/nutritional notes in the paper chart or electronic records and referred the surveyor to the registered dietitian. An interview on 12/11/19 at 8:25 AM with the Registered Dietitian (RD) revealed he/she had a system in place to ensure documentation was completed and stated he/she had meet with Resident #87 on 10/30/19 to address his likes and dislikes but could not find the documentation. The RD further stated he/she looked through the electronic medical records under multiple tabs and could not find any dietary/nutritional notes to indicate a dietary consult/assessment had been done for Resident #87. | 2020-09-01 |
| 3432 | 3432 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 840 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations and record reviews, the facility failed to ensure that a written contract/agreement was accessible for residents receiving [MEDICAL TREATMENT] services from outside resources. Resident #20 and #65 received outside facility [MEDICAL TREATMENT] services with no written agreement in place. Two of 2 [MEDICAL TREATMENT] residents reviewed. The findings included: An interview on 10/01/18 at approximately 11:30 AM facility administrator revealed the facility had residents that required [MEDICAL TREATMENT] services but the facility had no agreement/contract with an outside source for [MEDICAL TREATMENT] services. The facility admitted Resident #65 on 9/26/08 with [DIAGNOSES REDACTED]. An individual resident interview on 10/02/18 at approximately 8:35 AM revealed that Resident #65 [MEDICAL TREATMENT] lunch was not packed in an insulated container with ice packs. The resident stated he/she received items like macaroni salad, turkey sandwich, apple juice and fruit cup. The resident further stated that his/her meals were hot when he/she gets to eat and he/she does not like hot macaroni salad. A review of the medical record revealed a physician's orders [REDACTED]. The physician's orders [REDACTED]. The facility admitted Resident #20 on 5/11/16 with [DIAGNOSES REDACTED]. A review of the medical record on 10/01/18 revealed a physician's orders [REDACTED]. The cumulative physician's orders [REDACTED]. An interview and observation on 10/02/18 at approximately 11:58 AM with Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1 confirmed the observation. CNA #1 stated the resident meals are transported to [MEDICAL TREATMENT] in the white paper bags inside the clear paper bags. CNA #1 further stated there were no insulated containers to transport resident's food. An observation of the unit refrigerator ([NAME] 132) revealed there were no ice packs to use if insulated containers were available. An interview with th… | 2020-09-01 |
| 2526 | 2526 | PRUITTHEALTH- RIDGEWAY | 425288 | 213 TANGLEWOOD COURT | RIDGEWAY | SC | 29130 | 2018-06-15 | 692 | D | 1 | 1 | RRBC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to appropriately monitor the resident's weights to maintain appropriate nutrition parameters, resulting in significant weight loss, for 1 of 7 residents reviewed for nutrition. The findings included: Resident #76 was admitted to the facility, with diagnoses, including but not limited to, Gastro-[MEDICAL CONDITION] Reflux Disease, Hypertension, [MEDICAL CONDITIONS] Fibrillation, and Depression. To maintain appropriate and adequate nutritional status and values, the resident receives nutrition via tube feeding, as outlined in the physician's orders [REDACTED]. Review of the resident's recorded weights indicated the resident weighed approximately 177.4 pounds on 02/09/18. The resident was again weighed in March, on the 8th and weighed 160 pounds. The next weight was not captured until the next month in which the resident weighed 165 pounds. Review of the 'Weight Progress Notes Form' indicate a progress note written on 04/13/18, stating Current weight stable with increase to rate of nutrition and toleration. Increased ideal body weight. Weights monitored weekly x 3 , signed by the Dietary manager. The previous note was written on 05/30/17. Review of 'Enteral Feeding Progress Notes Form' indicated a progress note dated 02/06/18, signed by the dietician, in which the resident's nutritional needs were being met. The next note, dated 04/02/18, revealed significant weight decrease x past month, weight variability noted month to month A recommendation was made to increase the rate of the tube feedings. Review of nurse's notes and physician progress notes [REDACTED]. Review of the physician's orders [REDACTED]. Since this change the resident's weights have trended upward. During an interview with the Director of Nursing and the Administrator on 06/15/18, at approximately 10:12 a.m. it was discussed that residents are weighed monthly, unless orders dictate otherwise. Further interview wi… | 2020-09-01 |
| 2170 | 2170 | ROCK HILL POST ACUTE CARE CENTER | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2018-08-24 | 641 | D | 1 | 1 | C4HW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to ensure MDS assessment was coded accurately related to falls, for 1 of 4 reviewed for accidents. The findings included: Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. The Director of Nursing provided a list of falls the resident sustained [REDACTED]. Review of the resident's care plan reflected the resident's risk for falls, poor balance and safety awareness. Furthermore the care plan detailed the dates of the falls that occurred. Review of the Minimum Data Set quarterly assessment dated [DATE], indicated no falls since the admission or reentry. On 08/24/18 at 1:08pm the DON reviewed and confirmed the assessments to be inaccurately coded related to the number of falls sustained. | 2020-09-01 |
| 2524 | 2524 | PRUITTHEALTH- RIDGEWAY | 425288 | 213 TANGLEWOOD COURT | RIDGEWAY | SC | 29130 | 2018-06-15 | 679 | D | 1 | 1 | RRBC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to ensure to provide quality of care for 1 of 1 resident reviewed for activities. No activities were provided for Resident #105 during the week of the survey. The findings included: Resident#105 was admitted on [DATE] with [DIAGNOSES REDACTED]. During observation on 6/11/18 at 04:10 PM Resident was in her room while activities were occurring. Observation on 06/13/18 at 10:30 AM Resident was in her/his room TV was not on and no music. Observation on 06/14/18 at 3:30 PM Aromatherapy and Music activity was occurring but Resident #105 was not present. During record review on 6/15/18 at 9:10 AM revealed Care Plan Resident #105 unable to express her/his customary routine and or past leisure interest? Resident's siblings stated loved listening to gospel music. Approaches listed will accept small group programing and or individual programming visits from staff. During record review on 6/15/18 at 9:30 AM revealed Resident#105 Group Attendance Record Form have Actively Participated under other, but no documentation on the back of the form of what type of activities is listed for others. During interview with Activities Director on 6/15/18 at 9:50 AM, surveyor asked what type of activities are done with residents that are not alert and oriented. S/he stated will go by the family preference. Activities Director reviewed Resident# 105 activity forms and stated the Administrator just made me aware the other activities need to be listed on the form. | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );