cms_SC
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity ▼ | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 32 | 32 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 159 | B | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to to inform residents of balances in their personal funds for 2 of 12 residents interviewed.(Resident #48 & #46) The findings included: Record review of the Minimum Data Set(MDS) on 7/24/17 revealed Resident #48 had a Quarterly MDS dated [DATE] which listed the resident as having a 12 on the Brief Interview for Mental Status(BIMS). During an interview on 7/24/17 with Resident #48, he/she stated the facility did not inform him/her of the amount of money in his//her personal account. Record review of the MDS on 7/24/17 revealed Resident #46 had a Quarterly MDS dated [DATE] which listed the resident as having a 15 on the BIMS. During an interview on 7/24/17 with Resident #46, he/she stated the facility did not inform him/her of the amount of money in his/her personal account. During an interview with the Business Office Manager on 7/26/17 at 2:30 PM, he/she confirmed only a statement goes to the responsible party and not the resident. Information provided by the facility related to personal funds on 7/26/17 at 3:05 PM states the following: .A summary of activity is made available upon request and at least quarterly to each resident or resident representative . No additional information was presented as how the resident's knew they could request the balance of their personal account. | 2020-09-01 |
| 45 | 45 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 640 | B | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that required assessments were completed and/or transmitted as required for 4 of 4 residents reviewed for missing assessments. Four residents were noted with last transmission dates of greater than 120 days. Discharge assessments were not completed for three of these residents (Residents #315, #316, and #317). Resident #1 did not have a Quarterly Minimum Data Set (MDS) assessment transmitted. The findings included: Review of the MDS (Minimum Data Set) 3.0 Missing OBRA Assessment CASPER Report on 10/8/18 revealed the following: -The last assessment transmitted for Resident #317 was 4/1/18. -The last assessment transmitted for Resident #316 was 10/29/17. -The last assessment transmitted for Resident #315 was 10/15/17. -The last assessment transmitted for Resident #1 was 4/29/18. During an interview on 10/09/18 at 2:10 PM, the MDS Coordinator stated that Resident #317 was discharged on [DATE], #316 was discharged on [DATE], and #315 was discharged on [DATE]. No discharge assessments had been completed and transmitted for these residents. Additionally, s/he confirmed that the quarterly assessment for Resident #1 had an assessment reference date of 7/22/18 but had not been transmitted. | 2020-09-01 |
| 82 | 82 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 638 | B | 0 | 1 | NUHA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete an MDS (Minimal Data Set) Assessment within 92 days of the prior MDS assessment for Resident #10, 1 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #10 on 08/14/17 with [DIAGNOSES REDACTED]. On 09/05/18 at approximately 2:35 PM, review of the State Agency MDS data base revealed an Annual MDS assessment dated [DATE]. Further review revealed a discharge MDS assessment dated [DATE] and a Re-entry MDS dated [DATE]. No Quarterly MDS Assessment, with an Assessment Reference Date no later than 08/11/18 was noted. During an interview on 09/05/18 at approximately 4:30 PM, MDS Coordinator #1 stated a Quarterly MDS had been started but confirmed it was not completed and that s/he would investigate why the assessment wasn't completed. During an interview on 09/07/18 at 08:55 AM, MDS Coordinator #1 again confirmed the MDS was not done and stated another MDS Coordinator had reported that s/he thought it had been completed. | 2020-09-01 |
| 197 | 197 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 278 | B | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 sampled residents reviewed for contractures. Resident #94's MDS was not coded accurately to reflect the functional limitation of range of motion for the upper extremity contractures. The findings included: Resident #94 was admitted with [DIAGNOSES REDACTED]. During an observation on 10/3/17 at 10am, Resident #94 was observed to have contractures of her/his wrists and hands. Record review on 10/5/17 at 10am of hospice Interdisciplinary Team (IDT) Note on 3/8/17 stated, She (he) has bilateral hand contractures, and all extremities have fixed contractures and no purposeful use. Further record review of a Skilled Nursing (SN) Clinical Note dated 6/1/17 stated, All extremities with fixed contractures. Review of the MDS on 10/5/17 at 9am revealed the MDS with review dates of 6/6/17 and 8/31/17 was coded a 0-no impairment under Functional Limitation of Range of Motion, Section G0400, A- Upper Extremity. During an interview on 10/5/2017 at 12:50pm, MDS #1 verified that the 6/6/17 and 8/31/17 MDS was not coded correctly to reflect the upper extremity contractures. | 2020-09-01 |
| 221 | 221 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2018-08-09 | 582 | B | 0 | 1 | 3Y8D11 | Based on record review and interview the facility failed to submit beneficiary notices in a timely manner for 2 of 3 residents reviewed for beneficiary notices. Residents #87 and 269 were not informed of discharge from Medicare Part A services until after those services were discharged . The findings included: Review of beneficiary notices on 8/9/18 at approximately 12:13 PM revealed Resident #89 was discharged for m Medicare Part A services on 6/15/18. The denial letter (CMS-R-131) was not sent until 6/18/18 and the CMS-Notice of Medicare Non-Coverage (NOMNC) was not signed until 6/21/18. Review of beneficiary notices on 8/9/18 at approximately 12:13 PM revealed Resident #269 was discharged from Medicare Part A services on 4/3/18. The Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) and CMS-NOMNC were not signed until 4/4/18. Interview with Bookkeeper on 8/9/18 at approximately 12:20 PM confirmed these two residents were not informed of discharge from Medicare Part A services until after the services had been discharged . | 2020-09-01 |
| 362 | 362 | BLUE RIDGE IN GEORGETOWN | 425048 | 2715 SOUTH ISLAND ROAD | GEORGETOWN | SC | 29440 | 2017-03-30 | 167 | B | 0 | 1 | XEGY11 | Based on observations and interviews the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors and any plan of correction was readily available for resident /family and visitor review for 1 of 1 posting of survey results. The findings included: An observation on 3/27/2017 at approximately 9:00 AM of the recent Survey Results notebook revealed the survey results for (YEAR) and not the current (YEAR) results. A second observation on 3/30/2017 at approximately 2:00 PM revealed the (YEAR) State Survey results and the plan of correction and not the (YEAR) State Survey results. During an interview 3/29/2017 at approximately 5:21 PM with the facility Administrator concerning the Survey Results posting he/she stated, Someone must have removed it because a couple of weeks ago it was in the note book. The administrator then provided a copy of the (YEAR) State Survey results and included the results for 2013 and (YEAR). | 2020-09-01 |
| 669 | 669 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2018-04-06 | 641 | B | 0 | 1 | 3F6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure the Minimal Data Set (MDS) was accurately coded related to Nutritional Status. The MDS was coded incorrectly for Resident #38 to have a gastrostomy tube and Resident #82 to be on an incorrect diet. The findings included: Resident # 38 was admitted to the facility 11/20/2017 with [DIAGNOSES REDACTED]. During review of the Quarterly MDS with an Assessment Reference Date of 02/13/2018 Section K0510B2 was coded as checked (indicating the resident had a feeding tube.) Observation on 04/04/18 at 12:23 pm - Resident was in the unit dining room. Glasses on in w/c. lunch meal observation- 2% milk, Ensure pudding, and coffee, pureed diet, banana pudding desert, and prune juice. On 04/04/2018 during an interview the MDS Coordinator confirmed that the resident had never had a feeding tube and that Section K0510B2 was coded inaccurately. The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Record review on 4-5-18 at 12:24 PM revealed that upon admission, Resident #82 was on a full liquid diet and a physician's orders [REDACTED]. Review of the 3-24-18 30 day Minimum Data Set (MDS) assessment on 4-5-18 at 8:54 PM revealed that the mechanically altered diet was not coded under Section K. During an interview at 10:52 AM on 4-6-18, the MDS Coordinator verified that the MDS was not accurate related to the diet coding. | 2020-09-01 |
| 717 | 717 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2017-09-22 | 156 | B | 1 | 0 | MJSH11 | > Based on record review and interviews, two of three residents (Resident #72 and Resident #7 ) reviewed for Medicare notices of non-coverage was not done timely. The findings included: On 9/22/2017 at approximately 9:00 PM, the review was verified by the Social Worker of Resident #72's CMS - NOMNC, Notice of Medicare Non-Coverage, The Effective Date of Your Current MEDICARE Services Will End: 7/25/17. The form was signed by the RP (Responsible Party) of Resident #72 on 7/24/2017. Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS-1055, states; Date of Notice: 7/24/17, and was signed by RP on 7/24/2017. With reference to S&C-09-20: Generic/expedited notice must be issued no later that 2 days before the proposed end of services. On 9/22/2017: at approximately 9:15 PM, the review was verified by the Social Worker of Resident #7. The CMS -NOMNC Form states, The Effective Date of Your Current MEDICARE Services Will End: 7/25/17. The form was not signed by the RP (Responsible Party) of Resident #7. A handwritten notation on the bottom of the form states; LMSW (Licensed Medical Social Worker) spoke with RP, to advise him/her that therapy will end on 7/25/17. He/She does plan on appealing the decision. With reference to S&C-09-20: Residents or their legal representative must sign notices to verify receipt; however, if the resident is unable to receive the notice and the resident's legal representative is unavailable, the SNF (Skilled Nursing Facility) provider may contact the legal representative and inform him/her by phone .must immediately follow up .with a written notice. The date of telephone contact is considered to be the date the telephone notice was given as long as it is not disputed by the beneficiary. | 2020-09-01 |
| 725 | 725 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2017-09-22 | 287 | B | 1 | 0 | MJSH11 | > Based on record review and interview, the facility failed to transmit accurate and/or Minimum Data Set(MDS) information in the required time frame for 2 of 2 residents.(Resident #218 and #7) The findings included: The facility admitted Resident #218 who had an assessment target date of 3/15/17 which indicated a missing report per the Casper Report (SC) MDS 3.0 Missing OBRA Assessment. The facility admitted Resident #7 who had an assessment target date of 5/19/17 which indicated a missing report per the Casper Report (SC) MDS 3.0 Missing OBRA Assessment. During an interview with the Minimum Data Set Coordinator on 9/18/17, he/she stated Resident #218's discharge assessment had not been submitted and Resident #7's assessment listed an incorrect birth date. No policy was provided during he survey related to timely and accurate transmission of assessments. | 2020-09-01 |
| 755 | 755 | PRUITTHEALTH-ORANGEBURG | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2018-08-22 | 623 | B | 0 | 1 | MIO811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide written notice of transfer to 5 of 5 residents reviewed for hospitalization . The findings included; During record review on 8/21/2018 at approximately 1:35 PM, it was noted by this surveyor that Resident # 43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed s/he was ordered by the Physician to be sent out to The Regional Medical Center on 5/6/2018 due to [MEDICAL CONDITION] activity. The resident was then admitted and discharged back to the facility on [DATE]. Additional review indicated Resident #43 was ordered to be sent out to The Regional Medical Center on 5/30/2018 for [MEDICAL CONDITION] activity and decreased right side movement. S/he was then admitted and returned to the facility on [DATE]. Upon review of the Nursing Notes and Social Services Notes, it was indicated there had not been any documentation of the written notice of transfer being provided to the resident and/or their representative at the time of discharge. Other findings included; during record review on 8/21/18 at approximately 3:15 PM, it was noted that Resident #53 was ordered to be sent to the hospital on [DATE] for an evaluation. S/he was then admitted and returned back to the facility on [DATE]. There was no documentation of the written notice of transfer being provided to the resident or their Representative upon transfer. Additionally, Residents # 56 and 73 were also sent out with no written documentation of being provided with the written notice of transfer. An interview with the Administrator on 8/22/2018 verified the Resident's representatives are notified at the time of transfer, however, a written notice was not being provided at the time of transfer. The facility admitted Resident #73 on 05/07/10 with [DIAGNOSES REDACTED]. On 08/20/18 review of the nurses' notes revealed the resident was hospitalized from [DATE] until 07/23/18. The… | 2020-09-01 |
| 756 | 756 | PRUITTHEALTH-ORANGEBURG | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2018-08-22 | 625 | B | 0 | 1 | MIO811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide the bedhold policy with payment information to 5 of 5 residents reviewed for hospitalization . The findings included; During record review on 8/21/2018 at approximately 1:35 PM, it was noted by this surveyor that Resident # 43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed s/he was ordered by the Physician to be sent out to The Regional Medical Center on 5/6/2018 due to [MEDICAL CONDITION] activity. The resident was then admitted and discharged back to the facility on [DATE]. Additional review indicated Resident #43 was ordered to be sent out to The Regional Medical Center on 5/30/2018 for [MEDICAL CONDITION] activity and decreased right side movement. S/he was then admitted and returned to the facility on [DATE]. Upon review of the Nursing Notes and Social Services Notes, it was indicated there had not been any documentation of the bedhold policy being provided to the resident and/or their representative at the time of discharge. Other findings included; during record review on 8/21/18 at approximately 3:15 PM, it was noted that Resident #53 was ordered to be sent to the hospital on [DATE] for an evaluation. S/he was then admitted and returned back to the facility on [DATE]. There was no documentation of the bedhold policy being provided to the resident or their Representative upon transfer. Additionally, Residents # 56 and 73 were also sent out with no written documentation of being provided with the bedhold policy. An interview with the Administrator on 8/22/2018 verified the bedhold policy is signed upon admission, however, the facility was unaware that it was to be given at the time of transfer. The facility admitted Resident #73 on 05/07/10 with [DIAGNOSES REDACTED]. On 08/20/18 review of the nurses' notes revealed the resident was hospitalized from [DATE] until 07/23/18. There was no documentation that the f… | 2020-09-01 |
| 759 | 759 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2017-06-22 | 275 | B | 0 | 1 | RY7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete the yearly Minimal Data Set Assessment (MDS) (366 days) as required with Resident #57 for 1 of 17 reviewed for comprehensive assessment. The findings included: The facility admitted Resident # 57 with [DIAGNOSES REDACTED]. During the review of the MDS Assessment on 6/21/17 at 3:53 PM revealed the MDS assessment with Assessment Reference Date (ARD) 5/10/16 Assessment type yearly. The most recent assessment was completed with ARD 4/26/17 with Assessment Type Quarterly. No yearly assessment was found in the data base. During an interview on 6/22/17 at 10:19 AM, MDS Coordinator # 2 confirmed that the yearly assessment was not completed and that instead of the quarterly statement that was completed on 4/26/17 it should have been the yearly. | 2020-09-01 |
| 771 | 771 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2018-08-03 | 732 | B | 0 | 1 | 1MXI11 | Based on observation and interview, the facility failed to provide accurate information as required daily nurse postings for multiple days in (MONTH) (YEAR). The findings included: Review of the Report of Nursing Staff Directly Responsible for Resident Care posted daily by the facility revealed postings were not corrected to include staff changes on a daily basis for (MONTH) (YEAR). Additional review of postings for the months of (MONTH) and (MONTH) (YEAR) revealed the same. On (MONTH) 1, at approximately 10 AM, an interview with the Administrator confirmed the postings had not been updated to reflect schedule changes. | 2020-09-01 |
| 837 | 837 | SUNNY ACRES NURSING HOME | 425093 | 1727 BUCK SWAMP ROAD | FORK | SC | 29543 | 2017-04-20 | 287 | B | 0 | 1 | 2ZIO11 | Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments for Resident #126 was transmitted to the State Agency in a timely manner without error for 1 of 1 resident with missing MDS 3.0 OBRA Assessments. The findings included: Review on 4/20/2017 at approximately 2:00 PM of the missing assessment report from the facility revealed Resident #126 had missing MDS 3.0 OBRA Assessments and or errors during transmission to the state agency. An interview on 4/20/2017 at approximately 2:30 PM with the MDS (Minimum Data Set) assessment nurse confirmed the findings. The MDS assessment nurse went on to say, the message we got stated the assessments were accepted so therefore I did not follow up on it. This surveyor then presented the list of missing assessments to be corrected. | 2020-09-01 |
| 844 | 844 | SUNNY ACRES NURSING HOME | 425093 | 1727 BUCK SWAMP ROAD | FORK | SC | 29543 | 2018-08-17 | 915 | B | 0 | 1 | X2DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview the facility failed to ensure each resident's bedroom had a window to the outside. Two of 56 facility rooms did not meet that requirement. No actual harm resulted from the limited square footage. Findings include: Observation during a resident interview on 08/13/18 at 4:23 PM, revealed the only window in room [ROOM NUMBER]'s looked into the therapy room. During an interview on 08/14/18 at 9:45 AM, the Administrator stated he was not aware that room [ROOM NUMBER] did not have a window to the outside. Additional observation on 08/14/18 at 10:58 AM, revealed the only window in room [ROOM NUMBER] looked into an office. In an interview on 08/14/18 at 2:15 PM, the Maintenance Supervisor stated he was not aware that there were two resident rooms that did not have a window to the outside. | 2020-09-01 |
| 918 | 918 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 577 | B | 0 | 1 | 80ZB11 | Based on interview and observation the facility failed to post DHEC survey results accessible to all residents. The DHEC survey results were posted out of reach to wheel-chair bound residents. The findings included: Interview with Resident Council on 1/29/18 at approximately 3:20 PM revealed that the survey results were not accessible to those in the wheelchair. Observation on 1/29/18 at approximately 4:08 PM revealed the survey results were approximately 1 foot above the handrails and might not be accessible to all wheelchair bound residents. | 2020-09-01 |
| 951 | 951 | JOHN EDWARD HARTER NURSING CENTER | 425103 | 185 REVOLUTIONARY TRAIL | FAIRFAX | SC | 29827 | 2018-03-15 | 851 | B | 0 | 1 | UZQ111 | Based on observation and limited record reviews, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for the 1st, 2nd, and 4th quarters of Fiscal Year (FY) (YEAR), and the 1st quarter of FY (YEAR). Reports for 4 out of 5 quarters reviewed for FY (YEAR) and FY (YEAR). The findings included: Review of the Certification And Survey Provider Enhanced Report (CASPER) report 1702S Staffing Summary Reports for FY (YEAR) and the first quarter of FY (YEAR) generated 3/8/2018, on 3/13/18 at 5:30 PM revealed that report results for the following dates had no data returned for selected criteria for[NAME]Edward Harter Nursing Center: 10/01/2016 thru 12/31/2016-first quarter FY (YEAR) 01/01/2017 thru 03/31/2017-second quarter of FY (YEAR) 07/01/2017 thru 09/30/2017-third quarter of FY (YEAR) 10/01/2017 thru 12/31/2017-first quarter of FY (YEAR) Further review of the results of CASPER report 1702S Staffing Summary Report for the third quarter of FY (YEAR) (04/01/2017 thru 06/30/2017) revealed required information regarding staffing for this time frame that was submitted 07/18/2017, within the regulatory time frame of 45 days after the last day in the fiscal quarter. During interview with Director of Nursing (DON) and Minimum Data Set (MDS) nurse on 3/13/18 at 6:00 PM, they verified that there was no staffing data submitted for the first, second and third quarter of FY (YEAR) and the first quarter of FY (YEAR). DON reported that the Human Resources Manager (HRM) is responsible for submission of the information to the CMS database. Both DON and MDS nurse reported that they had verbalized concerns regarding submission of the staffing information when they had reviewed Quality Measures/5 Star Reporting information, but were assured that the information was… | 2020-09-01 |
| 1168 | 1168 | PRUITTHEALTH- DILLON | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2018-04-12 | 568 | B | 0 | 1 | D5V511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue quarterly statements for 2 of 2 residents reviewed. (Resident #53 & #9) The findings included: The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set listed the resident's Brief Interview for Mental Status(BIMS) as 10. During an interview with Resident #53 on 4/9/18 at 3:02 PM, s/he stated was unaware if s/he had a personal funds account when asked if they received a quarterly statement. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set listed the resident's BIMS as 10. During an interview with Resident #9 on 4/10/18 at 11:12 AM, s/he stated was unaware if s/he had a personal funds account when asked if they received a quarterly statement. During an interview with the Business Office Manager on 4/12/18 at 3:03 PM, s/he stated both residents had a personal funds account but had not requested a quarterly statements and the quarterly statements were sent to the responsible party. S/he continued by stating facility procedure was if a resident had a BIMS of 13 or above a quarterly statement is issued to the resident and the resident signs they received the statement. During an interview with the Business Office Manager on 4/12/18 at 4:12 PM, s/he stated there was no policy related to which residents received a quarterly statement, but s/he was instructed by corporate to issue one to those with a BIMS of 13 or above. | 2020-09-01 |
| 1208 | 1208 | HONORAGE NURSING CENTER | 425115 | 1207 NORTH CASHUA ROAD | FLORENCE | SC | 29501 | 2017-01-13 | 156 | B | 0 | 1 | CQPA11 | Based on record review and interview, the facility failed to utilize the required form for Notice of Medicare Non-coverage(NOMNC) for Resident #65(1 of 3 reviewed) and failed to issue the NOMNC in the required time frame for Resident #71.(1 of 3 reviewed). The findings included: Record review on 1/12/17 for Liability Notices revealed the facility issued Form No. CMS- for Resident #65 instead of the required Form No. CMS- -NOMNC. Further review revealed Form No. CMS- was not issued in the 48 hour required time frame for Resident #71. During an interview with the Business Office Manager on 1/12/17 at 11:12 AM, he/she confirmed Resident #65's notice was not on the required form and Resident #71's Liability Notice was not issued in the required 48 hour time frame. | 2020-09-01 |
| 1214 | 1214 | HONORAGE NURSING CENTER | 425115 | 1207 NORTH CASHUA ROAD | FLORENCE | SC | 29501 | 2017-01-13 | 354 | B | 0 | 1 | CQPA11 | Based on interview and record review the facility failed to insure that a Registered Nurse was assigned on duty for eight consecutive hours. The findings included: Review of the facility's licensed nursing staffing schedules for October, November, and (MONTH) up to (MONTH) 12, (YEAR) revealed that on Friday, (MONTH) 25, (YEAR), the Director of Nursing was scheduled to work on the unit as the Registered Nurse (RN) from 7 a- 3p. All other RN's were scheduled off for regular days off, vacations days , or holidays. On 1/12/17 at 1:45 PM in an interview with the DON ( Director of Nursing) she/he stated, I worked on that day in the facility as the RN and not as the DON. He/she further stated that he/she was unaware that the DON could not work in the facility as the RN coverage if the facility was over 60 beds. This facility is an 88 bed facility. | 2020-09-01 |
| 1424 | 1424 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2017-02-09 | 514 | B | 0 | 1 | 6GNK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the Physician 's Certification documentation to receive hospice care was not located in the chart for Resident # 23. ( 1 of 1 Hospice resident reviewed.) The findings included: The facility admitted Resident # 23 with [DIAGNOSES REDACTED]. An interview with RN ( Registered Nurse ) #1 @ 10:50 AM on 2/8/17 confirmed the recertification signatures were not in the Hospice notebook for dates 10/7/16- 12/16 and 12/17- 2/17. The DON ( Director of Nursing) stated she would call and have those sent to the facility from Hospice. They were later faxed from Hospice and placed in the Hospice Book for Resident # 23. | 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 |
| 1573 | 1573 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-10-05 | 842 | B | 0 | 1 | 5DS011 | Based on observations and interview, the facility failed to provide access to 1 of 24 sampled residents' records as required (Resident #88). The findings included: Upon entrance to the facility, it was noted that staff used both electronic and paper systems (chart) to comprise the complete medical records. Although the facility had a procedure for checking out charts at the nursing station, it was not being consistently utilized. The surveyor reviewed Resident #88's record on 10-2-18, but it was not in the chart rack at 9 AM on 10-3-18 and subsequently remained missing for 3 days of the survey. During an interview on 10/03/18 at 12 PM, the surveyor asked the Registered Nurse (RN) Consultant if s/he had been advised that Resident #88's hard chart had been missing since 9 AM. The RN verified they could not locate the chart and that it was not signed out per the facility policy. The Administrator and RN Consultant thought the Medical Director might have picked it up. On 10/04/18 at 8:32 AM, the Administrator stated they still had not located the chart. The chart was not found prior to exit on 10-5-18. | 2020-09-01 |
| 1584 | 1584 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2017-02-10 | 278 | B | 0 | 1 | 7B3F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview and observation, the facility failed to assure that 1 of 3 sampled residents reviewed for pressure ulcers and 1 of 5 sampled residents reviewed for unnecessary medications received accurate assessments. Resident #86 had 1 Annual Comprehensive Minimum Data Set (MDS) Assessment and 2 Quarterly MDS Assessments with inaccurate data related to Urinary Continence, active diagnoses, and Skin Conditions. Resident #34 had an Annual Comprehensive Minimum Data Set Assessment with inaccurate data related to active diagnoses. The findings included: The facility admitted Resident #86 with [DIAGNOSES REDACTED]. Record review of Resident #86's Quarterly MDS with ARD of 8/15/2016, and Quarterly MDS with ARD of 11/15/2016 on 2/9/2017 at 8:45 AM revealed Section G Items G0400A (Functional limitation in Range of Motion (ROM) in upper extremities and G0400B (Functional limitation in ROM in lower extremities) are both coded as 0, which indicated no impairment in functional ROM. Record review of Resident #86's PACE (Program of All-Inclusive Care for the Elderly) Care Plan Review dated 8/12/16 on 2/9/2017 at approximately 10:20 AM, reveals that an Occupational Therapy (OT) Assessment was completed on 8/2/16 which identified limitations in range of motion in both arms and a Physical Therapy (PT) Assessment was completed on 8/10/2016 which identified .significant decrease range of motion of bilateral knees. Further review revealed that an OT periodic review completed on 1/5/2017 identified ROM deficits and multiple contractures in all extremities with potential for pain, further contracture formation, and skin breakdown . During interview on 2/9/2017 at approximately 8:19 am, C.N.[NAME] #10 verified that Resident # 86 had had contractures in bilateral arms and legs .as long as I can remember. During an interview on 2/9/17 at approximately 8:40 AM, LPN #3 verified that Resident #86 had contractures in arms and legs on both sides. Di… | 2020-09-01 |
| 1586 | 1586 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2017-02-10 | 287 | B | 0 | 1 | 7B3F11 | Based on interview and electronic record review the facility failed to complete and transmit required Minimum Data System (MDS) 3.0 assessments as required by CMS and the State for discharged residents. The findings included: On 02/09/2017 at 1:45 PM an interview with MDS RN #1 and electronic record review of residents #147, #148, #149, #150, #151, #152, #153, #154, #155 had missing and/or incomplete discharge assessments encoded and transmitted. | 2020-09-01 |
| 1598 | 1598 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2018-06-01 | 640 | B | 0 | 1 | VRCK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review and staff interview, the facility failed to ensure that one of three residents identified on the Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation (OBRA) Assessment Report had assessments electronically transmitted to the Centers for Medicare and Medicaid (CMS) system database as mandated. Resident #282's Prospective Payment System (PPS) 5 day start of therapy discharge return not anticipated Minimum Data Set (MDS) assessment was electronically transmitted to the Centers for Medicare and Medicaid (CMS) database System 98 days after discharge date and was considered to be late. The findings included: Review of the resident record on 5/31/18 at 8:45 AM revealed that Resident #282 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Missing OBRA MDS assessment Report on 5/29/18 at 10:30 AM revealed that Resident #282 ' s last received assessment was an entry tracking form with a target date of 2/20/2018. Review of the Final Validation Report (FVR) on 5/31/18 at 12:40 PM revealed that a discharge assessment was submitted and accepted to the CMS system database on 5/31/18 at 12:27 PM. Further review of the FVR revealed a submission ID of 269 and Resident #282 ' s Discharge MDS assessment is identified as Record 1. Additional review of the FVR revealed that the discharge MDS assessment for Resident #282 was accepted, with message -3810d WARNING Record Submitted Late: The submission date is more than 14 days after Z0500B2 on this new (A0050 equals 1) assessment. During interview with MDS Nurse #1 on 5/31/18 at 1:51 PM, s/he verified that the MDS assessment for Resident #282 was completed on 2/26/18 but not submitted and accepted by the CMS system database until 5/31/18 and was considered late according to regulatory guidelines outlined in the RAI manual. | 2020-09-01 |
| 1738 | 1738 | PRUITTHEALTH-MONCKS CORNER | 425140 | 505 SOUTH LIVE OAK DRIVE | MONCKS CORNER | SC | 29461 | 2018-05-25 | 640 | B | 0 | 1 | ZKXB11 | Based on record review and interview, the facility failed to complete and/or transmit required assessments in a timely manner for 9 of 9 sampled residents reviewed for Missing Assessments. The findings included: Record review and interview on 05/25/18 at approximately 6:06 PM with the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse #2 , revealed that corrections were made and reports resubmitted based upon Missing OBRA assessments listed on the CASPER 3 report. | 2020-09-01 |
| 1764 | 1764 | PRUITTHEALTH-MONCKS CORNER | 425140 | 505 SOUTH LIVE OAK DRIVE | MONCKS CORNER | SC | 29461 | 2019-07-19 | 640 | B | 0 | 1 | IPGW11 | Based on record review and interview, the facility failed to complete and transmit Discharge Tracking MDS (Minimum Data Set) Assessments for 3 of 4 residents reviewed for missing assessments (Residents #425, #426, and #427). The findings included: Review of the state database revealed Admission MDS Assessments for Residents #425 dated 12/22/18, #426 dated 10/19/18, and #427 dated 09/28/18. Further review revealed no Discharge Tracking MDS Assessments for Residents #425, #426, or #427. Review of the facility's current electronic health records revealed Residents #425, #426, and #427 did not have any entries in the current system. During an interview with the MDS Coordinator on 07/19/19 09:35 AM, s/he confirmed the Discharge Tracking MDS for Resident #425 was not completed in the software system. S/he further confirmed the Discharge Tracking MDS for Residents #426 and #427 was completed but not closed or transmitted. The MDS Coordinator further stated that s/he runs an open assessment report each month but the residents assessments did not appear on the report. | 2020-09-01 |
| 1786 | 1786 | HEARTLAND HEALTH CARE CENTER - UNION | 425142 | 709 RICE AVENUE | UNION | SC | 29379 | 2018-07-12 | 657 | B | 0 | 1 | EY8011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required members of the Interdisciplinary Team participated in the development of care plans for 5 of 21 residents reviewed for care plans. (Residents #32, 4, 69, 33, and 77) The findings included: The facility admitted Resident #32 on 6/13/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 6/25/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #4 on 4/11/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 4/17/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #69 on 8/25/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 12/7/17, 3/13/18, and 6/2/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #33 on 4/22/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 1/18/18 and 4/11/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #77 on 6/14/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participatin… | 2020-09-01 |
| 1798 | 1798 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2017-07-14 | 156 | B | 1 | 1 | EIV311 | > Based on record review and interviews, the facility failed to follow guidelines for issuance of the Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (CMS -NOMNC) to Resident #4. Timely notice was not given to 1 of 3 residents reviewed for Liability Notices. The findings include: Record review on 07/13/17 at 3:46 pm revealed that the facility provided less than the required two day notice to Resident #4 for the Notice of Medicare Non-coverage. Further review of the file revealed that Resident #4's benefit period was due to end on 01/25/17. The notice provided by the facility was dated 01/24/17. In an interview on 07/13/17 at 4:11 pm the Social Worker stated that the notice should have been done on 01/23/17 to meet the two day requirement. | 2020-09-01 |
| 1799 | 1799 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2017-07-14 | 167 | B | 1 | 1 | EIV311 | > Based on observation and interview the facility failed to post signage indicating the location of past survey results and making them readily accessible to both residents and visitors. The findings included: On 07/14/2017 11:42 AM this surveyor along with the Administrator observed placement of the facility's mandatory posting of contact information for state regulatory agencies, the Ombudsman and other advocacy groups. In an interview on 07/14/17 at 11:42 AM the Administrator confirmed that the board contained out-of-date and repetitive information. The Administrator stated that a resident would need to ask for assistance to select the proper contact information. Further observation revealed the facility's past survey results to be placed in a notebook in a mail bin on the left wall of the entrance hall to the dining room. In an interview on 07/14/17 at 11:42 AM, the Administrator was asked, how would a person entering the front door of the facility know where to find the survey results without asking for assistance. The Administrator stated there should be a sign to tell them. | 2020-09-01 |
| 1802 | 1802 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2017-07-14 | 276 | B | 1 | 1 | EIV311 | > Based on record review and interview, the facility failed to submit a Minimum Data Set (MDS) OBRA quarterly assessment in a timely manner for 4 of 4 residents reviewed for MDS transmission of records. (Residents #96, #80, #69, and #12) The findings included: Review of the facility's MDS 3.0 Missing OBRA Assessment report revealed Resident's #96, #80, #69, and #12 were listed on the report. During an interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the report. The MDS Coordinator later provided a report indicating the missing quarterly assessments had been submitted. The MDS Coordinator confirmed that the quarterly assessments were not submitted within the required timeframe. | 2020-09-01 |
| 1959 | 1959 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2018-01-26 | 574 | B | 0 | 1 | OHH911 | Based on observation, interview and record review, the facility failed to ensure The Resident Council was aware of how to file a complaint with the South [NAME]ina State Survey Agency for 1 of 1 Resident Council meetings. The findings included: During The Resident Council Group Meeting held on 01/ 18/18 at 02:04 PM the residents stated they did not receive information on how to file a complaint with the state. The only person who knew about the Ombudsman was a resident who was in rehab and stated she was told at her Assisted Living placement facility. During an interview on 01/26/18 at 05:30 PM, the Activities Director verified that she had not discussed in the resident council meetings about how to file a grievance with the state, but she does tell them where the phone numbers are posted. He/she stated and showed evidence where the Ombudsman information is posted for the residents to contact. | 2020-09-01 |
| 1963 | 1963 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2018-01-26 | 640 | B | 0 | 1 | OHH911 | Based on record review, interview, and review of the facility policy titled MDS-Automation/Electronic Submission, the facility failed to transmit accurate Minimum Data Set(MDS) information in the required time frame for 1 of 1 resident. (Resident #2) The findings included: The facility admitted Resident #2 who had an assessment target date of 7/29/17 which was the last assessment per the Casper Report. During an interview with the MDS Coordinator on 1/19/18 at 4:56 PM, , s/he stated the assessment was probably rejected due to an inaccurate ID number. Review of the facility policy MDS-Automation/Electronic Submission revealed the following: The facility will electronically submit via matrix its state-specific version of the Minimum Data Set(MDS) within the required timeframes according to applicable law and regulations. | 2020-09-01 |
| 2001 | 2001 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 582 | B | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure that each resident received proper notice of expiration of Medicare benefits for 1 of 3 residents reviewed for beneficiary protection notification. The findings included: Record review on [DATE] at 4:07PM proved that Resident #80 was not given a 48 hour notice of when his/her Medicare benefits will expire. The Notice of Medicare Non-Coverage form stated that services will end on [DATE], however the Resident signed the form on [DATE]. The Director of Nursing (DON) confirmed that the Resident was not notified 48 hours before Medicare benefits expired. | 2020-09-01 |
| 2124 | 2124 | RIDGEWAY MANOR HEALTHCARE CENTER | 425158 | 117 BELLFIELD ROAD | RIDGEWAY | SC | 29130 | 2018-05-24 | 640 | B | 0 | 1 | CL5J11 | Based on limited record review and interview, the facility failed to electronically transmit encoded, accurate, and completed Minimum Data Sheet (MDS) to the Centers of Medicare and Medicaid Services (CMS) for 1 of 1 reviewed for missing MDS assessment. The findings included: Review of the missing MDS Assessments on 5/21/18 at 10:31 AM revealed the facility failed to transmit MDS assessment for Resident #44 target date 12/8/17. During an interview on 5/23/18 at 3:01 PM with Regional MDS Assessment confirmed Resident # 44 MDS assessment was not submitted within the target date. S/he completed the submission on 5/21/18. | 2020-09-01 |
| 2129 | 2129 | RIDGEWAY MANOR HEALTHCARE CENTER | 425158 | 117 BELLFIELD ROAD | RIDGEWAY | SC | 29130 | 2018-05-24 | 727 | B | 0 | 1 | CL5J11 | Based on limited record reviews and interviews the facility failed to have a RN coverage for 4 out of 30 days reviewed. The findings included: Review of the facility postings and subsequent schedules and time punches revealed the facility did not have required coverage for Registered Nursing on 04/28/18, 04/29/18, 05/12/18, and 05/13/18, for 30 days reviewed. The Director of Nursing and Administrator indicated they were aware of this matter. | 2020-09-01 |
| 2202 | 2202 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2017-11-16 | 287 | B | 0 | 1 | DKQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a corrected Resident Initial Identification number on 12/15/2016 and therefore had resident information mismatch for Resident #84 for 1 of 1 resident reviewed with missing OBRA Assessments. The findings included: Review on 11/14/2017 at approximately 11:20 AM of a CMS (Centers for Medicare and Medicaid) Submission Report dated 12/15/2016 revealed an assessment for Resident #84 with a Resident Information Mismatch due to the Resident Initial Identification number did not match the values in the QIES ASAP database. The new information was not corrected by the facility. During an interview on 11/14/2017 at approximately 11:25 AM with the MDS (Minimum Data Set) assessment Coordinator, he/she confirmed the findings. The quarterly assessment dated [DATE] contained the corrected Resident Initial Identification number for Resident #84. | 2020-09-01 |
| 2250 | 2250 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2017-04-21 | 156 | B | 0 | 1 | 9IUY11 | Based on record review and interviews, one of three residents (Resident #11) reviewed for Medicare notices of non-coverage was not notified in writing following a telephone notification. The findings included: On 4/21/17 at 08:30 AM, review of Resident #11's Medicare Determination on Continued Stay-Skilled Nursing/Facility form revealed D. This is to confirm that you were advised of the noncoverage of the services under Medicare by telephone on 11/8/16. The Beneficiary's name was written on the bottom of form with the signature of the Administrative Officer. The CMS -NOMNC Form was also not signed by the beneficiary. At the bottom of Form CMS -NOMNC, a signed and witnessed handwritten notation stated, 11/18/16 at 3:06 PM Spoke with (family member) concerning (Resident #11). I let her(him) know that she(he) will be moved off of Medicare because she(he) met her(his) goals and prior level of function. She(He) has the right to appeal and gave her(him) the number. On 4/21/17 at 8:49 AM, the Business Office Manager verified that a letter had not been sent to Resident #11 following the telephone notification of Medicare non-coverage. The Business Office Manager said,; Normally we talk to resident or family. With reference to S&C-09-20: Residents or their legal representative must sign notices to verify receipt; however, if the resident is unable to receive the notice and the resident's legal representative is unavailable, the SNF (Skilled Nursing Facility) provider may contact the legal representative and inform him/her by phone .must immediately follow up .with a written notice. The date of telephone contact is considered to be the date the telephone notice was given as long as it is not disputed by the beneficiary. | 2020-09-01 |
| 2383 | 2383 | PRUITTHEALTH-CONWAY AT CONWAY MEDICAL CENTER | 425173 | 2379 CYPRESS CIRCLE | CONWAY | SC | 29526 | 2018-08-10 | 640 | B | 0 | 1 | 6SJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) assessment dated [DATE] for Resident #229 was coded correctly before transmission to the State Agency for 1 of 1 resident on the Missing OBRA Assessments report. The findings included: Review on 8/10/2018 at approximately 4:42 PM of the Missing OBRA Assessment report revealed an assessment missing for Resident #229. Further review on 8/10/2018 at approximately 4:42 PM of the transmission report to the State Agency revealed the date of birth for Resident #229 was coded incorrectly on the MDS assessment transmitted on 1/8/2018. During an interview on 8/10/2018 at approximately 4:50 PM with the MDS/Care Plan Coordinator, he/she confirmed that the date of birth for Resident #229 was coded incorrectly before transmitting to the State Agency. | 2020-09-01 |
| 2529 | 2529 | PRUITTHEALTH- RIDGEWAY | 425288 | 213 TANGLEWOOD COURT | RIDGEWAY | SC | 29130 | 2018-06-15 | 842 | B | 1 | 0 | RRBC11 | > Based on limited record review and interview the facility failed to accurately document the Active Daily Livings (ADLs) Assistant and Support form for document the Active Daily Living for 1 of 2 reviewed for ADLS. Resident #176's ADLs were documented the day after leaving the facility. The findings included: During record review on 06/13/18 at 10:50AM revealed Discharge Recapitulation Form dated 11/04/17 Resident #176 left the facility against medical advice. Further record review on 06/15/18 at 12:05 PM revealed on November 05, 2017 Resident # 176 ADLS information were completed. During an interview with DON on 06/15/18 at 3:39 PM confirmed Resident #176's ADL information was not complete until 06/05/17. | 2020-09-01 |
| 2588 | 2588 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2017-06-21 | 156 | B | 0 | 1 | K48X11 | Based on record review and interview, the facility failed to provide a required Advance Beneficiary Notice (ABN) of Non-coverage of medicare CMS (Centers for Medicare/Medicaid Services) form for 2 of 3 sampled residents reviewed. Residents #32 and #57 did not receive ABN forms. The findings included: An interview on 6/20/17 at approximately 10:48 AM with the Business Office Manager confirmed Residents #32 and #57 who had additional medicare days left and remained in the facility did not receive the required ABN form or other medicare notice that addressed the request for a demand bill. | 2020-09-01 |
| 2625 | 2625 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2017-05-10 | 356 | B | 0 | 1 | T7X811 | Based on record review and interview, the facility failed to retain the nurse staffing postings for 18 months as required. The findings included: A review of the nurse staffing postings during the Extended Survey on 4/28/17 revealed the facility kept past postings in a notebook. A review of the documents revealed the following postings were missing: 12/31/16; 1/1/17; 1/2/17; 1/7/17; 1/8/17; 1/14/17; 1/15/17; 1/21/17; 1/22/17; and 1/24/17-1/31/17. Missing postings for (MONTH) (YEAR) included 2/1/17-2/6/17; 2/8/17; and 2/10/17-2/27/17. Missing postings for (MONTH) (YEAR) included 3/1/17-3/7/17; 3/9/17-3/23/17; and 3/25/17-3/31/17. Missing postings for (MONTH) (YEAR) included 4/1/17; 4/2/17; 4/6/17-4/11/17; 4/14/17-4/17/17; 4/19/17; and 4/20/2017. During an interview on 4/28/17 at approximately 12:57, the Administrator confirmed that staff was unable to locate the missing postings and confirmed that the above postings were not retained. The Administrator stated that it was the responsibility of the Assistant Director of Nursing to retain the daily staffing postings. | 2020-09-01 |
| 2688 | 2688 | PRINCE GEORGE HEALTHCARE CENTER | 425295 | 901 MAPLE STREET | GEORGETOWN | SC | 29440 | 2019-09-19 | 640 | B | 0 | 1 | TX1R11 | Based on record review and interview, the facility failed to ensure the timely transmission of Comprehensive Assessments for 2 of 2 Resident Assessments listed on facility reports. The findings included: Record review of the Missing OBRA Assessment report revealed Resident #1's comprehensive Minimum Data Set (MDS) assessment with a target date of 4/13/19 and Resident #2's comprehensive MDS assessment with a target date of 4/11/19 were not submitted. In an interview on 09/16/19 at approximately 12:30 PM, the MDS Coordinator reviewed the Missing OBRA Assessment report and stated s/he researched the submissions but could not provide a reason as to why the reports were not transmitted timely but would re-attempt. | 2020-09-01 |
| 2755 | 2755 | LAKE MARION NURSING FACILITY | 425300 | 1527 URBANA ROAD | SUMMERTON | SC | 29148 | 2017-05-11 | 156 | B | 0 | 1 | 2GZW11 | Based on record review and interview, the facility failed to issue a liability notice of non coverage for Resident #1375 in a timely manner for 1 of 3 residents reviewed for Liability Notices. The findings included: Review on 5/11/2017 at approximately 2:30 PM of a form titled, Notice of Medicare Non-Coverage - CMS -NOMNC, revealed an effective date of ending skilled nursing services as 12/2/2016 and was signed by Resident #1375's personal representative on 12/1/2016 not allowing the required 48 hours for appeal if desired. Review on 5/11/2017 at approximately 2:30 PM of a form titled, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS- revealed a signature by Resident #1375's responsible party on 12/1/2016. During an interview on 5/11/2017 at approximately 2:40 PM the Administrator and the Social Service Director confirmed the findings and stated that Resident #1375's responsible party should have been notified at least 2 days (48 hours) prior to the Medicare Non-Coverage ending date. | 2020-09-01 |
| 2780 | 2780 | RICHARD M CAMPBELL VETERANS NURSING HOME | 425301 | 4605 BELTON HIGHWAY | ANDERSON | SC | 29621 | 2018-04-19 | 640 | B | 0 | 1 | 2DMF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete/ encode Minimum Data Set (MDS) 3.0 information within required 7 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 3 of 3 residents identified as not having assessments completed within 120 days. The findings included: Resident #5 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #1 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #2 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. | 2020-09-01 |
| 2787 | 2787 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2017-06-16 | 167 | B | 0 | 1 | BF3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to inform residents where the current State Survey Results were located and how to access previous surveys, certifications and complaint investigations. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 6/16/17 revealed a Quarterly Minimum (MDS) data set [DATE] which listed the resident's Brief Interview for Mental Status as 11. During an interview with Resident #45 on 6/16/17, he/she stated the facility had not informed residents of where the State Survey Results were located. Review of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Resident Council Minutes revealed Resident #45 attended each meeting. Further review of the minutes revealed the location of the State Survey Results had not been discussed with the residents. Observation of the facility revealed a notice had been placed on the bulletin board of the location of the latest survey results. The State Survey Results were observed at the beginning of the hallway near the Administrator's office. Further observation revealed there was no notice posted in the facility related to the past three years of surveys, certifications and complaint investigations were available upon request. | 2020-09-01 |
| 2814 | 2814 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-04-25 | 582 | B | 0 | 1 | IJ5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Notice of Medicare Non-coverage (NOMAC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for 2 of 3 residents reviewed for NOMAC and SNF ABN. (Residents #71 and #77) The findings included: Record review revealed Resident #71 was admitted to the facility on [DATE]. Record review revealed Resident #71 remains in the facility but was discharged from Medicate Part A services on 04-16-19 with Part A days remaining. Review of the Skilled Nursing Facility Protection Notification Review on 04-24-19 at approximately 10:30 AM revealed, the facility did not provide the SNF ABN or NOMAC to Resident #71 or to his/her representative. Record review revealed Resident #77 was admitted to the facility on [DATE]. Record review revealed Resident #77 remains in the facility but was discharged from Medicate Part A services on 04-04-19 with Part A days remaining. Review of the Skilled Nursing Facility Protection Notification Review on 04-24-19 at approximately 10:30 AM revealed, the facility did not provide the SNF ABN or NOMAC to (Resident #77 and Resident #71) or to their representatives. Resident #71 and #77 remained in the facility after discharge from Medicare Part A services with Part A days remaining. During an interview on 04-24-19 at approximately 11:04 AM, the Social Service Assistant confirmed the facility did not complete and give the SNF ABN or the NOMAC to the resident (Resident #71 and Resident #77) or their representative. | 2020-09-01 |
| 2963 | 2963 | BLUE RIDGE OF SUMTER | 425310 | 1761 PINEWOOD ROAD | SUMTER | SC | 29154 | 2017-12-15 | 574 | B | 0 | 1 | DK0Z11 | Based on interviews, record reviews, and the facility's policy titled Resident's Rights, the facility failed to ensure that residents are informed of the Ombudsman's contact information and how to formally file a complaint with the State Agency for residents #3, #42, and #62. 3 of 4 residents who attended Resident Council Group Discussion Meeting. The findings included: Review on 12/12/17 at 11:02 AM of Resident Council Minutes for the months of (MONTH) through (MONTH) revealed no discussion about posting of the Ombudsman's contact information, results of the State Inspection, and information on filing a complaint with the State. During an interview with the residents' on 12/13/17 at 11:30 AM, the question was asked Do residents know where the ombudsman's contact information is posted? Have residents been informed of their right to formally complain to the State about the care they are receiving? Residents' # 3, #42, and #62 stated No. During an interview with the Social Services Director on 12/15/17 at 9:28 AM, s/he confirmed there was no discussion on Ombudsman's contact information, results of State Inspections, and filing a complaint with the state. Review of the Admission Packet on 12/15/17 at 11:24 AM revealed no information on contact information on Advocate Agency Contact and filing a complaint with the State Agency Information. In addition with the facility's policy Resident Rights no information on State Agency Advocacy. | 2020-09-01 |
| 2964 | 2964 | BLUE RIDGE OF SUMTER | 425310 | 1761 PINEWOOD ROAD | SUMTER | SC | 29154 | 2017-12-15 | 577 | B | 0 | 1 | DK0Z11 | Based on interviews and record reviews the facility failed to ensure that residents are aware of the Survey Inspections for residents #3, #42 and #62. Three of 4 residents who attended Resident Council Group Discussion Meeting. The findings included: Review on 12/12/17 at 11:02 AM of Resident Council Minutes for the months of (MONTH) through (MONTH) revealed no discussion about posting of the Ombudsman's contact information, results of the State Inspection, and information on filing a complaint with the State. During an interview with the residents' on 12/13/17 at 11:30 AM, the question was asked Without having to ask, are the results of the State Inspection available to read? Residents' # 3, #42, and #62 stated no. During an interview with the Social Services Director on 12/15/17 at 9:28 AM, s/he confirmed there was no discussion on Ombudsman's contact information, results of State Inspections, and filing a complaint with the state. Review of the Admission Packet on 12/15/17 at 11:24 AM revealed no information on contact information on Advocate Agency Contact and Reporting Information. In addition with the facility's policy Resident Rights no information on State Agency Advocacy. | 2020-09-01 |
| 3015 | 3015 | MUSC HEALTH MULLINS NURSING HOME | 425312 | 518 S MAIN STREET | MULLINS | SC | 29574 | 2018-03-02 | 851 | B | 1 | 1 | X83O11 | > Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 10/1/16-12/31/16 submitted 2/27/17; Staffing Summary Report 1/1/17-3/31/17 submitted 5/16/17. During an interview with staff responsible for the Payroll Based Journal on 3/2/18, s/he stated the submissions were done in a timely manner and did not understand why the CASPER Reports appeared untimely. | 2020-09-01 |
| 3116 | 3116 | GOLDEN AGE INMAN | 425316 | 82 N MAIN STREET | INMAN | SC | 29349 | 2017-04-12 | 356 | B | 0 | 1 | V7AN11 | Based on observation, interview, and record review the facility failed to correctly fill out staff posting information. Daily postings of licensed and unlicensed care staff were incomplete for 2 of 4 days of survey and 3 days of a 30-day look back. The findings included: Observation of the posting for nursing staff on 4/11/17 at approximately 12:06 PM revealed that cumulative hours of nursing staff were not posted for each shift. Observation of posting for nursing staff on 4/12/17 at approximately 8:48 AM revealed that the posting was incomplete. The number of licensed and registered nurses for each shift as well as the cumulative hours worked were not listed for each shift. Interview with the DON on 4/12/17 at approximately 9 AM confirmed that the nurse staffing information sheet was incomplete. S/he then corrected the posting by filling out the blank sheet. Review of the previous 30 days of nurse staffing information on 4/12/17 at approximately 10:42 AM revealed that days 3/15/17, 3/25/17, and 3/26/17 were incomplete. These days were missing either the number of nurses worked or the cumulative hours worked. | 2020-09-01 |
| 3153 | 3153 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2017-02-02 | 287 | B | 0 | 1 | UFWZ11 | Based on review of missing Minimum Data Set (MDS) Assessments and interview with the MDS Coordinator, the facility failed to transmit MDS Assessments for the following residents: Resident #106, Resident #107, and Resident #108. The findings included: Review of missing MDS Assessments on 2/2/17 at approximately 1:00 PM revealed that the facility failed to transmit MDS Assessments for Residents #106, #107 and #108. Interview with MDS Coordinator on 2/2/17 at approximately 1:50 PM revealed that Resident #106 had been discharged , but the discharge assessment was not yet completed nor transmitted. Resident #106's Assessment Reference Date (ARD) was 6/1/16. Resident #107 was also discharged , but the discharge assessment was not closed or transmitted. The resident's ARD was 8/22/16. Resident #108 had also been discharged , but the discharge assessment had not been closed or transmitted. The resident's ARD was 7/2/16. The MDS Coordinator confirmed s/he was aware that MDS Assessments need to be closed and transmitted within 14 days. | 2020-09-01 |
| 3233 | 3233 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2018-10-18 | 640 | B | 0 | 1 | 2VYN11 | Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set) assessments were transmitted to the state agency in a timely manner for Resident #1, # 2 and #3. The findings included: Review on 10/17/2018 at approximately 8:40 AM of the Resident Assessment Task of the Long Term Care Survey Process revealed Resident #1 and Resident #2 with MDS assessments over 120 days old not transmitted to the state agency. Further review on 10/17/2018 at approximately 8:50 AM of the Missing OBRA Assessment report dated 10/10/2018 revealed an MDS assessment for Resident #3 not transmitted timely to the state agency. During an interview on 10/17/2018 at approximately 2:10 PM with the MDS/Care Plan Coordinator, he/she stated I have been late in transmitting assessments. | 2020-09-01 |
| 3377 | 3377 | LAKE MOULTRIE NURSING HOME | 425341 | 1038 MCGILL LANE | SAINT STEPHEN | SC | 29479 | 2018-08-31 | 640 | B | 0 | 1 | RRPE11 | The facility failed to transmit an assessment timely for Resident #238. No harm resulted to the resident. | 2020-09-01 |
| 3428 | 3428 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 582 | B | 1 | 1 | 2F3711 | > Based on interview with administrator and record review the facility failed to provide advance beneficiary notices for 1 of 1 resident reviewed for Medicare discharges. Resident #3 was discharged from Medicare Part A on 4/22/18 but the resident representative was not notified in advance. The findings included: Review of Denial Letter and CMS - Notice of Medicare Non-Coverage for Resident #3 on 10/2/18 at approximately 1:30 PM revealed neither forms had been signed by the resident representative. Interview with administrator on 10/2/18 at approximately 2:08 PM revealed the resident's representative was mailed the notice forms but never returned them and verbally expressed understanding. The administrator provided the tracking forms of the forms that had been mailed, but review of tracking forms indicated the notice forms were not sent out until 4/21/18 or received until 4/23/18. | 2020-09-01 |
| 3583 | 3583 | BETHEA BAPTIST HEALTHCARE CENTER | 425372 | 157 HOME AVENUE | DARLINGTON | SC | 29532 | 2019-01-18 | 640 | B | 0 | 1 | Q96O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit required assessments in a timely manner for 2 of 8 residents reviewed for transmission. The Minimum Data Set (MDS) was not transmitted as required for Residents #1 and 76. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/18/19 revealed the last MDS received was dated 8/12/18. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 1/18/19 revealed the last MDS received was dated 1/24/18. Interview with the MDS Coordinator on 1/18/19 at 10:25 AM revealed the transmission of the two assessments was missed. | 2020-09-01 |
| 3747 | 3747 | WILDEWOOD DOWNS | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2018-02-23 | 640 | B | 0 | 1 | IZ8B11 | Based on record review, interview, and review of the facility's policy titled, Resident Assessment RAI, the facility failed to electronically transmit encoded, accurate, and completed Minimum Data Sheet (MDS) to the Centers of Medicare and Medicaid (CMS) for 12 out of 24 reviewed for MDS assessments. The findings included: Review of the missing MDS Assessments on 2/20/17 revealed that the facility failed to transmit MDS assessments for Residents # 1, 2, 3, 4, 92, 93, 94, 95, 96, 97, 98, and 99. During the interview 02/23/18 09:40AM with the MDS Coordinator, DON, ADON, and Director of Clinical Services. MDS Coordinator stated when the facility started using electronic software we were having problems transmitting. Director of Clinical Services confirmed they were having problems and unable to provide the results from the submission on the Casper Report MDS 3.0 Missing OBRA Assessment. Review of the facility's policy titled, Resident Assessment RAI, states 5. All MDS assessments will be transmitted per CMS guidelines as illustrated in Chapters 2 and 5. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. | 2020-09-01 |
| 3785 | 3785 | RICE NURSING HOME | 425387 | 100 FINLEY ROAD | COLUMBIA | SC | 29203 | 2017-03-02 | 278 | B | 0 | 1 | JR9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess one of one sampled resident reviewed for Hospice. Resident #102 had two Minimum Data Set (MDS) assessments coded incorrectly, related to terminal diagnosis. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. Record review on 3/2/17 at 9:00 am revealed a physician's orders [REDACTED]. The Hospice certification was signed by the Physician and Hospice team. This certification stated, This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. Review of the 3/21/16 and 12/9/2016 quarterly and significant change MDS assessments revealed they were coded incorrectly in Section J, Health Conditions, J1400 Prognosis. Although the Hospice Certification of Terminal Illness was present, the MDS was coded to indicate Resident #102 did not have a life expectancy of less than 6 months. During an interview on 3/2/17 at 10:18 am with MDS Nurse #2, s/he confirmed J1400 was coded incorrectly on both assessments. | 2020-09-01 |
| 4023 | 4023 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 160 | B | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to release funds within 30 days of death for 2 of 3 sampled residents reviewed for personal funds. Resident #121 and Resident #135 did not have their funds released within 30 days of their death. The findings included: On [DATE] at 2:45pm, review of records with the Business Office Manager revealed Resident #121 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. Further review revealed Resident #135 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. During an interview on [DATE] at 2pm, the facility administrator stated they did not have a policy, but followed Center for Medicaid/Medicare Services (C[CONDITION]) regulations. | 2020-09-01 |
| 4152 | 4152 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2017-09-14 | 356 | B | 0 | 1 | 3N1E11 | Based on record review and interview, the facility failed to post the total number of hours worked for Licensed Practical Nurses for 7 days and for Registered Nurses for 2 days. The findings included: During the Initial Survey, on 09/14/17, review of the facility ' s staff posting revealed 7days which did not reflect the total number of hours worked by Licensed Practical Nurses. Further review revealed 2 days which did not reflect the total number or hours worked by Registered Nurses. During an interview on 09/14/17, the Director of Nursing confirmed the postings did not include the total hours worked. | 2020-09-01 |
| 4165 | 4165 | BISHOP GADSDEN EPISCOPAL HEALTH CARE CENTER | 425411 | 1 BISHOP GADSDEN WAY | CHARLESTON | SC | 29412 | 2019-01-31 | 640 | B | 0 | 1 | S24T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit required assessments in a timely manner for 2 of 2 residents reviewed for transmission. The Minimum Data Set (MDS) was not transmitted as required for Resident #1 and #2. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/28/19 revealed the last MDS received was dated 8/8/18. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 1/28/19 revealed the last MDS received was dated 9/6/18. During an interview on 1/28/19 at approximately 2:00 PM, the MDS Coordinator confirmed the assessments had been completed but not transmitted as required. | 2020-09-01 |
| 4227 | 4227 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2017-03-23 | 287 | B | 0 | 1 | UZ0811 | Based on record review, interview and review of the facility policy titled Transmission Policy, the facility failed to transmit accurate Minimum Data Set(MDS) information in the required time frame for 1 of 1 resident. The findings included: The facility admitted Resident #189 who had an assessment target date of 12/19/16 which was the last assessment per the Casper Report. During an interview with Registered Nurse(RN)#2 on 3/23/17, he/she stated the next assessment was never finalized by the previous MDS Coordinator and there was no explanation as to why the assessment had not been completed and submitted. He/she further stated an assessment was completed on 3/3/17 and submitted on 3/8/17. Review of the facility policy titled Transmission Policy revealed the following: A calendar of all assessments will be maintained in the care plan office. Assessments will be transmitted at least every two weeks . | 2020-05-01 |
| 4236 | 4236 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2016-06-16 | 156 | B | 0 | 1 | 3I0411 | Based on record review and interviews, the facility failed to provide in writing a list, of services that the resident on Medicaid, may and may not be billed for, for one of one resident sampled, (resident #382). Findings included - Interview with the responsible party for resident #382 by telephone on 6/14/16 at 2:24 PM revealed the facility did not provide a copy of services Medicaid would and would not pay for. Review of resident #382's business office file lacked evidence the facility provided the resident's responsible party a copy of the list of services that Medicaid would and would not pay for. Interview with administrative staff 1 in her office on 6/16/16 at 11:02 am revealed, the facility would discuss verbally with the resident and/or responsible party what the financial liability would be. But if the resident was going to have a service that was not covered by Medicaid, the facility would notify the resident or responsible party prior to the resident receiving the service. The facility failed to provide a written list of services that Medicaid would and would not cover for this resident | 2020-05-01 |
| 4283 | 4283 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2016-07-12 | 356 | B | 0 | 1 | 443S11 | Based on record review and interviews, the facility failed to post staffing information on a daily basis as required. Postings available for review failed to include resident census and the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift. Lack of posting information had the potential to affect all residents and visitors who desired to obtain this information. The findings included: During the extended survey on 7-7-16, staff postings (1-1-16 through 6-30-16) were requested for review. The Administrator provided a notebook that s/he stated contained the requested information. The Director of Healthcare Services (DHS) provided a copy of the documents for review at 12:12 PM on 7-7-16. Review of the POS [REDACTED]. Restorative personnel were listed at the bottom of the forms with neither scheduled or actual hours noted. January, (YEAR) Postings were not available for the following dates: 1-1, 1-2, 1-3, 1-4,1-6 through 1-17, 1-19 through 1-24, and 1-26 through 1-31-16. The postings did not include the census on the following dates: 1-5, 1-18, and 1-25-16. Duplicate forms were reviewed that included discrepant staffing information and/or were missing census data for 1-18-16. February, (YEAR) Postings were not available for the following dates: 2-2, 2-3, and 2-4-16. The postings did not include the census on the following dates: 2-10, 2-11, 2-13, 2-18, 2-20, and 2-22-16. Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 2-1, 2-12, 2-16, 2-18, 2-19, 2-20, 2-22, 2-25, 2-26, 2-27, 2-28, and 2-28-18. March, (YEAR) Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 3-1, 3-9, 3-11, 3-12, 3-14, and 3-28-18. April, (YEAR) A posting was not available for 4-11-16. Multiple duplicate forms were reviewed that included discrepant staffing information and were mis… | 2020-04-01 |
| 4288 | 4288 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2016-12-15 | 156 | B | 0 | 1 | N3QC11 | Based on record review and interview, the facility failed to utilize the required form for Notice of Medicare Non-Coverage(NOMNC) for Residents #14 and #54(2 of 3 reviewed) , failed to accurately complete a Skilled Nursing Facility Advance Beneficiary Notice(SNFABN) for Resident #49(1 of 3 reviewed) and failed to issue the NOMNC for Resident #49(1 of 3 reviewed). The findings included: Record review on 12/15/16 for Liability Notices revealed the facility issued Form No. CMS- to Residents #14 and #54 instead of the required Form No. CMS- -NOMNC. Further review revealed the SNFABN notice for Resident #49 did not indicate which option the resident and/or authorized representative desired. In addition, Form No. CMS- -NOMNC was not issued to Resident #49. During an interview with the Administrator on 12/15/16 at 2:26 PM, he/she was not aware of the newest Form No. -NOMNC nor was he/she aware Form No. -NOMNC needed to be issued in conjunction with the SNFABN. No policy was provided for Liability notices during the survey process. | 2020-04-01 |
| 4313 | 4313 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2016-09-09 | 356 | B | 0 | 1 | JH7U11 | Based on observation, interview, and record review, the facility failed to post cumulative staff hours for licensed and unlicensed staff on 1 of 1 units. The finding included: Observation during Stage 1 of survey on 9/06/2016 at approximately 4:00 PM revealed the nurse staff posting on Unit 1 did not list cumulative hours worked by licensed and unlicensed staff. Observation during Stage 1 of survey on 9/07/2016 at approximately 9:45 AM revealed the nurse staff posting on Unit 1 did not list cumulative hours worked by licensed and unlicensed staff. Interview with Director of Nursing (DON) on 9/07/2016 at approximately 10:25 AM confirmed the cumulative hours for licensed and unlicensed staff were not posted with nurse staffing information. Review of the prior month of nurse staff postings on 9/07/2016 at approximately 2:15 PM revealed that nurse staff postings had not listed the cumulative hours worked by licensed and unlicensed staff. | 2020-04-01 |
| 4438 | 4438 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2016-06-23 | 356 | B | 0 | 1 | 45NR11 | Based on observations and interviews, the staffing posting was not readily accessible to residents and visitors on 2 of 3 units in the main building. Postings were located behind the nurses' desks. The findings included: Multiple observations (6-20-16 during Initial Tour, 6-21-16 at 10 AM, 6-22-16 at 10 AM and 3:20 PM) revealed that the staffing posting was located behind the Units 1 and 2 nursing stations. They were not posted in a prominent place, readily accessible to residents and visitors. During an interview on 6-23-16 at 10:20 AM, Licensed Practical Nurse #1 verified the posting was on the wall on a paper (8.5 inches x 11.5 inches) behind the nurses desk on Unit 1. | 2020-01-01 |
| 4532 | 4532 | DUNDEE MANOR, LLC | 425118 | 710 15-401 BYPASS, WEST | BENNETTSVILLE | SC | 29512 | 2016-06-09 | 156 | B | 0 | 1 | UM6B11 | Based on record review and interview the facility failed to provide adequate Notice of Medicare Non-Coverage for 1 of 3 residents, (#21) sampled for liability and appeal notices. Findings included: Review of the Notice of Medicare Non-Coverage the facility provided for resident (#21's) coverage that ended 12/13/15 revealed the notice lacked documentation of what services would no longer be covered. The facility also failed to provide a explanation for the reason of non-coverage and failed to provide the number and name of the Quality Improvement Organization. During interview on 6/09/16 at 1:13 PM SW #1 acknowledged when staff filled out the Non-Coverage form the facility failed to provide the number to contact for the Quality Improvement Organization (QIO), failed to provide an explanation of what services would no longer be covered and why the facility determined services were not covered. | 2019-11-01 |
| 4555 | 4555 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2016-09-09 | 156 | B | 0 | 1 | 706J11 | Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notice to 1 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #45.) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 9/9/16 revealed that Resident #45 had been discharged from Medicare Part A services with Medicare eligibility days remaining, and Resident #45 remained in the facility. The surveyor requested to review the required CMS Form for Resident #45. At that time, the Social Services Director informed the surveyor that he/she did not issue CMS Form . | 2019-11-01 |
| 4559 | 4559 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 160 | B | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Trust account and interview, the facility failed to convey the personal funds and a final accounting upon death within 30 days to the named executor or probate jurisdiction administering the individuals' estates for 2 of 3 expired residents. One of the three sampled residents (Resident #149) reviewed had funds which were not released within 30 days. One of the 3 sampled residents reviewed (Resident #24) had a cash balance issued to an unauthorized family member. The findings included: A closed record review of personal funds was conducted on [DATE] at 3:42 PM with the Business Office Manager (BOM). Review of the Admit/Discharge Report for [DATE] through [DATE] revealed that Resident #149 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $394.36 issued via check #1164 to close the trust account on [DATE]. The date of issue was verified by the BOM. Review of the Admit)Discharge Report revealed that Resident #24 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $38.00 issued via cash ticket #245 to CASH TO RESIDENT which closed the trust account on [DATE]. Review of the Resident Trust Petty Cash Withdrawal Sheet with the BOM revealed that an individual signed receipt for the $38 remaining in the account. The BOM was unable to provide evidence that the monies were received by a named executor or a person authorized by the court. | 2019-11-01 |
| 4803 | 4803 | STILL HOPES EPISCOPAL RETIREMENT COMMUNITY | 425401 | 1 STILL HOPES DRIVE | WEST COLUMBIA | SC | 29169 | 2016-07-07 | 156 | B | 0 | 1 | 2KGG11 | Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notice to 1 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #13) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 7/06/16 at approximately 3:30 PM revealed that Resident #13 had been discharged from Medicare Part A services with Medicare eligibility days remaining. At the time of the review, the Social Services Director stated that CMS Form -NOMNC had not been issued for Resident #13. The Social Services Director further indicated that he/she had not been in the facility at the time Resident #13 was discharged from Medicare Part A services, and the form was not issued as required prior to discharge. | 2019-08-01 |
| 4898 | 4898 | PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO | 425393 | 801 MUSGROVE STREET | CLINTON | SC | 29325 | 2016-05-25 | 156 | B | 0 | 1 | B82Q11 | Based on record review and interview, the facility failed to provide a detailed explanation of the reason coverage for services should not continue. Resident #27 was not issued the CMS- -DENC (Detailed Explanation of Non-Coverage) as required upon appeal for Medicare coverage. The findings included: During a review for issuance of liability notices on 5-25-16 at 12 PM, Resident #27 was noted to have been issued a CMS- -NOMNC (Notice of Medicare Non-Coverage) and a UR (Utilization Review) COMMITTEE DETERMINATION ON CONTINUED STAY letter on 4-6-16. At that time, Medicare non-coverage was appealed. There was no evidence that the detailed explanation about why coverage for services should not continue (CMS- -DENC) was issued to the beneficiary. While conducting the review, Social Services stated s/he was unaware that the Form CMS- -DENC should have been provided, | 2019-07-01 |
| 4957 | 4957 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2018-06-07 | 851 | B | 0 | 1 | K3CB11 | Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid Services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 4/1/2017-6/30/2017 submitted 8/23/17 During an interview with staff responsible for the Payroll Based Journal on 6/7/18, s/he stated the submissions were done in a timely manner and did not understand why the CASPER Reports appeared untimely. | 2019-07-01 |
| 5576 | 5576 | SANDPIPER REHAB & NURSING | 425146 | 1049 ANNA KNAPP BOULEVARD | MOUNT PLEASANT | SC | 29464 | 2015-04-01 | 156 | B | 0 | 1 | RGIM11 | Based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -Notice of Medicare Non-Coverage (NOMNC) Form, the Medicare Liability Notices and Beneficiary Appeal Rights, and/or the CMS -Advanced Beneficiary Notice (ABN), for 2 of 4 sampled residents discharged from Medicare A with days remaining and remaining in the facility with/without a new payer source. (Resident #38 and Resident #134) The findings included: On 03-31-15 at approximately 10:00 AM, review of Resident #38's and Resident #134's funds revealed the facility staff failed to complete the required CMS- (ABN), for Resident #38 who had been discharged from Medicare A with days remaining and remained in the facility under an alternate payer source. The facility further failed to complete the required CMS- NOMNC and the required CMS- for Resident #134. Resident #134 had been taken off of Medicare Part A, had Medicare days remaining, and remained in the facility. Resident #134 had not received therapy. During an interview on 03-31-15 at approximately 10:00 AM with Registered Nurse (RN) #4, h/she confirmed the above findings. | 2018-11-01 |
| 5727 | 5727 | DR RONALD E MCNAIR NURSING & REHABILITATION CENTER | 425309 | 56 GENESIS DRIVE | LAKE CITY | SC | 29560 | 2015-03-05 | 167 | B | 0 | 1 | HFE711 | Based on observation and interview, the facility failed to ensure that the results of the most recent surveys of the facility were readily accessible for 2 of 2 nursing units. The findings included: During a Group interview on 3/4/15, 6 of 6 alert and oriented residents stated they did not know where the survey results were located. Following the conclusion of the interview, observation of the location of the survey results revealed the survey was posted, in a clear plastic sheet protector, on a bulletin board in the common hallway between the 2 nursing units. The survey was posted approximately 6 feet from the floor and the top page in the sheet protector was the DHEC (Department of Health and Environmental Control) cover letter. Observation also revealed the survey was posted with 17 additional pamphlets and notices on the bulletin board. In addition. there was a bulletin board directly to the right with 8 notices/pamphlets and one to the left with 9 notices/pamphlets. During an interview at that time, the Nursing Home Administrator (NHA) confirmed the location of the survey results and stated s/he thought it was a good location, at eye level for anyone walking by. The NHA also confirmed that most of the facility's residents were in wheel chairs. When asked if wheel chair bound residents could see or reach the results without asking a staff member for assistance, the NHA stated I see what you mean. | 2018-10-01 |
| 5769 | 5769 | COVENANT TOWERS HEALTHCARE CENTER | 425382 | 5001 LITTLE RIVER ROAD | MYRTLE BEACH | SC | 29577 | 2017-03-09 | 156 | B | 0 | 1 | NH9U11 | Based on record review and interview the facility failed to issue a required CMS form or 1 of 5 CMS (Centers for Medicare and Medicaid) approved denial letters for Resident #17 with ending coverage of Medicare part A with days remaining and remained in the facility for 1 of 3 residents reviewed for Liability Notices. The findings included: The facility admitted Resident #17 for Rehabilitation/Therapy Services. Review on 3/9/2017 at approximately 3:54 PM of a form titled, Notice of Medicare Non-Coverage, revealed that current services will end on 11/10/2016 and was signed on 11/07/2017 by the resident's responsible party. Per the Social Services Director Resident #17 had days remaining and was going to remain a resident in the facility. Further review on 3/9/2017 at approximately 4:00 PM of the medical record for Resident #17 revealed no CMS form nor 1 of 5 CMS approved denial letters had been issued. During an interview on 3/9/2017 at approximately 4:00 PM with the Billing Manager, he/she stated, I was filling in for the Social Worker and I forgot to issue the CMS or any of the 1 of 5 CMS approved denial letters. | 2018-10-01 |
| 5816 | 5816 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2015-02-24 | 159 | B | 0 | 1 | R9Q011 | Based on resident funds review and interview the facility failed to notify three of three residents (or legal representatives) when their accounts reached $200 less than the SSI resource limit. The facility failed to provide evidence that Residents C, D, and E had been notified that their accounts were reaching the resource limit as required and the residents might lose eligibility for Medicaid or SSI. The findings included: Funds review was conducted on 2/24/15 with the Business Office Manager. A Trial Balance sheet was produced listing fund amounts held by the facility. The Business Office Manager indicated the three accounts showing balances over $1800 were Medicaid recipients. The Manager stated their computer program would print out the names of those at $1800 limit and would also print out a form letter to be sent to the resident/legal representative. The Manager stated this had been done; however, there was no documentation of who was informed or when. No records or copies of the letters had been kept to verify the notification. The Business Office Consultant verified this at that time. | 2018-08-01 |
| 6107 | 6107 | WINDSOR MANOR | 425114 | 5583 SUMMERTON HIGHWAY | MANNING | SC | 29102 | 2014-11-13 | 156 | B | 0 | 1 | NM5A11 | Based on record review, interview and review of the facility policy entitled Medicare Part A/Advantage Program, the facility failed to provide 2 of 2 sampled residents reviewed with appropriate generic and liability notices prior to ending Medicare Part A coverage. Residents #4 and #61 were not provided the required Centers for Medicare and Medicaid (CMS) -NOMNC (Notice of Medicare Non-Coverage) or liability notices (CMS or one of the five CMS-approved notices) prior to denial of Medicare Part A services. The findings included: On 11-12-14 at 10 AM, the Administrative Assistant provided a list of 3 residents who had changed from Medicare Part A coverage to other pay sources since 1-1-14 as a result of a facility determination of non-coverage. One of the residents was noted as discharged to the hospital and therefor was not reviewed. During an interview at 3:30 PM on 11-12-14, the Administrative Assistant stated that Resident #4's first non-covered day was 11-7-14. S/he provided a form that was marked as a CMS and a CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN). An attached form noted that the responsible party was notified of the non-coverage on 9-5-14 and did not request an appeal. ****Denial Letter Only was noted next to the appeal denial. This, then, did not address the expedited appeal rights to the Quality Improvement Organization (QIO) referred to in the CMS- . The Administrative Assistant verified that the CMS NOMNC (Approved 12/31/2011) had not been provided as required. The Administrative Assistant stated that Resident #61's first non-covered day was 7-3-14. S/he provided a form that was marked as a CMS and a CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN). An attached form noted that the responsible party was notified of the non-coverage on 6-30-14 and did not request an appeal. ****Denial Letter Only was noted next to the appeal denial. This, then, did not address the expedited appeal rights to the Quality Improvement Organization (QIO) referred to in the CMS- . The Administrative… | 2018-05-01 |
| 6245 | 6245 | BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2014-09-04 | 160 | B | 0 | 1 | 0BDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy, Resident Funds, the facility failed to convey funds deposited with the facility to the estate of the resident or to the probate court for Resident #C and #D, 2 of 3 residents reviewed for conveyance of funds. The findings included: On [DATE] at 11:13 AM, review of the conveyance of funds upon the death of Residents C revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the Power of Attorney (POA) on [DATE]. Review of review of the conveyance of funds upon the death of Residents D revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the POA on [DATE]. During an interview at that time, the Business Analyst confirmed the trust fund balances were paid to the Power of Attorney for both Residents. The Account Specialist confirmed They're supposed to go to the Estate of. When asked why the accounts were paid to the POA, the Account Specialist stated that the Power of Attorney for both residents had deposited $50.00 in the residents' account just in case. Upon the residents' death the POA for both residents had requested the money, stating it was their money in the first place and s/he had paid out the accounts, in cash, to the POA in both instances. Review of the facility's policy, Trust Funds, revealed Upon the death of a Resident with a personal fund, the business office will convey within 30 days the Resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the Resident's estate. | 2018-04-01 |
| 6368 | 6368 | BROOKDALE ANDERSON | 425398 | 311 SIMPSON RD | ANDERSON | SC | 29621 | 2014-10-15 | 156 | B | 0 | 1 | E65111 | Based on record review and interview, the facility failed to use the correct liability notices for 1 of 3 residents reviewed. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS- was not used for 1 resident reviewed who was discontinued from Medicare Part A with days remaining and stayed in the facility. The findings included: Review of liability notices for Resident #5 on 10/14/14 at 9:00 AM revealed the resident's skilled nursing/therapy services ended on 9/8/14 and the resident converted to private pay on 9/9/14. Further review revealed the Power of Attorney (POA) for Resident #5 signed Form -NOMNC (Notice of Medicare Non-Coverage), but the facility did not have the POA sign the SNFABN Form CMS- as required. Interview with the Business Office Director on 10/14/14 at 9:15 AM confirmed these findings and revealed that a company letter was used instead of the SNFABN Form CMS- . The Business Office Director further stated that the SNFABN Form CMS- was being used, but only for residents who did not remain in the facility. | 2018-04-01 |
| 6438 | 6438 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2011-06-01 | 156 | B | 0 | 1 | BPHS11 | On the days of the survey based on record review and interview, the facility failed to notify the residents of charges not covered under Medicare for 2 of 3 Notices of Medicare Non-Coverage reviewed for timely notification. The facility was not using the CMS Form for 2 of 3 sampled residents for notification and was unaware of the CMS Form . The findings included: On 6/1/11 at 11:55 AM a review of 3 random residents for Medicare Non-Coverage Notification revealed that 2 of the 3 did not have the correct forms for notification and were not provided with the required 48 hour prior notice. In at interview with the Administrator at that time, she revealed that she had taken over the responsibility of the Medicare Notices in the past year, was confused about the forms and was not sure that she was using the correct forms. She was not sure when to use the CMS Form and was unaware of the CMS Form . | 2018-02-01 |
| 6552 | 6552 | WILLOW BROOK COURT AT PARK POINTE VILLAGE | 425375 | 3025 CHESBROUGH BLVD | ROCK HILL | SC | 29732 | 2014-10-08 | 156 | B | 0 | 1 | HQ2811 | Based on observation and interviews, the facility failed to prominently display written information regarding how to receive refunds for previous payments on 1 of 1 units. The findings included: On 10/7/14 at 10:10 AM, the facility's postings were observed in a wooden case with glass doors. No information was posted regarding the process for applying for refunds. In addition, the case was located with the top approximately 8-10 inches from the ceiling. During an interview at that time, the Nursing Home Administrator confirmed there was no information posted regarding how to apply for refunds. The Administrator further confirmed that residents in wheelchairs might have difficulty seeing the postings at the top of the cabinet. | 2018-01-01 |
| 6612 | 6612 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2014-11-18 | 156 | B | 0 | 1 | 7DWW11 | Based on record review and interview, the facility failed to provide notice of rights, rules, services, and charges. The facility failed to use the correct and most current form for notification of Medicare non-coverage for 3 of 3 denial notices reviewed, and failed to provide 48 hour notice for 1 of 3 denial notices reviewed. The findings included: Record review of the Medicare denial letters was conducted on 11/18/14. The Social Worker provided a Notice of Medicare Provider Non-Coverage (CMS- ) letter dated 7/28/14 for a resident who was denied continued coverage due to issues related to participation. Further review revealed services ended on 7/28/14 and the Responsible Party signed the form on 8/4/14. Interview with the Social Worker on 11/18/14 at approximately 12:30 PM revealed the Responsible Party had been notified by telephone prior to the date the form was signed, but there was no documentation of this. The Social Worker provided Notice of Medicare Provider Non-Coverage (CMS- ) letters dated 9/29/14 and 11/7/14 for two residents who had met their Physical Therapy and Occupational Therapy goals. An interview with the Corporate Consultant on 11/18/14 at approximately 1:00 PM confirmed the facility was not using the CMS- NOMNC (Notice of Medicare Non Coverage) form as required by the Centers for Medicare and Medicaid Services. | 2017-12-01 |
| 6901 | 6901 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2014-03-20 | 156 | B | 0 | 1 | 85TP11 | On the days of the survey, based on interview, record review and review of the facility postings for the Ombudsman services, the facility failed to ensure residents were knowledgeable of the role and availability of the Ombudsman. Neither Resident # 103 nor Resident # 54 were aware of the services of the Ombudsman when interviewed. (2 of 2 residents interviewed related to resident rights) The deficient practice had the potential to affect multiple residents who could have the need of the Ombudsman services. The findings included: Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on resident interview conducted on 3/18/14 at approximately 3:30 PM and 3/19 at approximately 10:15 AM, neither resident was aware of the role of the Ombudsman or how to reach them to obtain their services. Both resident's stated information concerning resident rights had not been covered during their Resident Council Meetings or provided by other means to them. Review of the Resident Council Minutes from September 2013 to present revealed no documentation of a discussion concerning the role of the Ombudsman or how to obtain their services. A tour of the facility on 3/19/14 at 2:15 PM revealed one informational Ombudsman poster located across from Administrators office, letter sized, in a frame hung above standing eye level. A further tour revealed no additional posting accessible for resident's seated in a wheelchair as verified by the facility consultant during an interview on 3/19/14 at 3:07 PM. | 2017-08-01 |
| 6902 | 6902 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2014-03-20 | 167 | B | 0 | 1 | 85TP11 | On the days of the survey, based on record review, interview, and observation, the facility failed to assure residents were knowledgeable in the location/availability of the most recent survey results and failed to post a notice of their availability. The deficient practice had the potential to affect multiple residents who desired to review the most recent survey results. The findings included: Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on resident interviews conducted on 3/18/14 at approximately 3:30 PM and 3/19 at approximately 10:15 AM, neither resident was aware that the Stage Agency issued a written report of survey findings nor the location of the document. On 3/19/14 at 2: 40 PM, a binder containing survey results was located on a table in the front lobby. This area was separated from the resident's living area by a doorway that remained closed at all times making independent wheelchair access difficult. Additionally, the door was alarmed so any resident wearing an exit prevention device could not enter the area without assistance and further supervision. During an interview with the facility Nurse Consultant at that time,s/he confirmed the location of the survey results. S/he also verified the door was maintained in a closed position; any resident who wanted to look at the binder who was unable to open the door would have to ask for assistance; and there was no posting indicating the location of the survey results. Review of the facility Resident Council minutes for the past 6 months, revealed the last time the Council was informed of their right to look at survey results was in September 2013 and Resident # 54 was not a resident at that time. | 2017-08-01 |
| 6903 | 6903 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2014-03-20 | 170 | B | 0 | 1 | 85TP11 | On the days of the survey, based on interviews, the facility failed to assure the resident of the right to receive mail based on the currently available Postal delivery schedule. The facility had requested no mail delivery on Saturdays. The deficient practice had the potential to affect any resident who received mail in the facility. The findings included, Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on the resident interview conducted on 3/18/14 at approximately 4 PM and 3/19 at approximately 10:15 AM, neither Resident was able to state if mail was delivered on Saturday. Resident # 103 stated his/her mail did not come to the facility at all and Resident # 54 was unsure. During an interview with the Activity Director (AD) immediately following the interview with Resident 103, the AD stated the Activity Department was responsible for the delivery of resident mail. The Activity Director stated no mail delivery occurred at the facility on Saturdays. Further interview with the facility Administrator on 3/19/14 at approximately 9:30 AM, revealed Saturday mail had not occurred at the facility since 2009 under the direction of previous Administration. The Saturday mail delivery had been discontinued by facility choice and not due to postal restrictions. The Administrator stated s/he had contacted the Postal services and would be no problem resuming Saturday mail delivery. | 2017-08-01 |
| 6907 | 6907 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2013-08-29 | 160 | B | 0 | 1 | 2M6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview, the facility failed to convey resident funds of 2 of 3 sampled residents reviewed within 30 days of death as required. The findings included: During an interview and review of Resident Trust records with the Business Manager on [DATE] at 2:55 PM, s/he confirmed the following: (1) Resident #39 expired on [DATE]. The balance in the Resident Trust was issued to the estate of . on [DATE] (31 days). (2) Resident #66 expired on [DATE]. The balance in the Resident Trust was issued to the estate of . on [DATE] (31 days). During the interview, the Business Manager stated s/he had been routinely releasing the funds the same date in the following month. Thus, if any resident expired in a month with 31 days, the monies were not released in a timely manner. | 2017-08-01 |
| 7399 | 7399 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2013-02-07 | 160 | B | 0 | 1 | 44DM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the survey, based on review of funds and interviews, the facility failed to convey funds to the to the individual or probate jurisdiction administering the resident's estate. (1 of 1 deceased resident funds reviewed.) The findings included: During a review of resident fund accounts on [DATE] at approximately 12:30 PM, resident funds for 1 of 1 residents deceased were not conveyed per regulatory requirement. An interview on [DATE] at approximately 12:30 PM with the Administrator verified the resident fund balance was not issued to the probate jurisdiction administering the resident's estate. | 2017-03-01 |
| 7863 | 7863 | LORIS REHAB AND NURSING CENTER, LLC | 425086 | 3620 STEVENS STREET | LORIS | SC | 29569 | 2012-08-29 | 160 | B | 0 | 1 | HQQ311 | On the days of the survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate for 2 of 3 random sampled residents reviewed. Two residents' funds were conveyed to individuals without documentation to indicate they had individual jurisdiction to administer the resident's estate. The findings included: An interview on 8/28/12 at approximately 4:20 PM with the Business Office Manager confirmed the findings that 2 of 3 random sampled residents' funds reviewed were conveyed to individuals without documentation to indicate the individual had jurisdiction to administer the resident's estate. | 2016-10-01 |
| 8542 | 8542 | BROOKDALE ANDERSON | 425398 | 311 SIMPSON RD | ANDERSON | SC | 29621 | 2012-01-12 | 159 | B | 0 | 1 | 25JC11 | On the days of the survey, based on interviews occurring during fund review, the facility failed to maintain resident funds in access of fifty dollars in an interest bearing account with written authorization. The findings included: During an interview with the Social Services Director on 1/12/12 , she revealed that she encouraged residents to not bring money to the facility. If the residents insisted, she would sometimes place their money in an envelope with their name on it and place the envelope in a locked box in her office. The residents did not sign/authorize for her to maintain their funds. When asked: Would you take $60.00 from a resident and keep it for them? The Director stated, I would strongly encourage them not to bring the money to the facility; but upon insistence by the resident, I would place it in the lock box. The Social Service Director stated she was unaware that resident funds amounts over $50.00 must be in an interest bearing account and that she did not maintain an accounting of funds held for the residents. In an earlier interview conducted on 1/12/12 with the Business Office Manager, she stated the facility did not keep any personal funds for residents. | 2016-03-01 |
| 8594 | 8594 | LIFE CARE CENTER OF CHARLESTON | 425332 | 2600 ELMS PLANTATION BLVD | N CHARLESTON | SC | 29406 | 2012-02-23 | 167 | B | 0 | 1 | TKRT11 | On the days of the survey, based on observation and interview, the facility failed to have the most recent survey or notification of where those results were located , posted in a readily accessible place, frequented by the residents and other individuals at 1 of 2 separate entrances that is separated from the other part of the building by a dementia unit. The findings included: On 02/21, 02/22, and 02/23/12, the most recent survey or notification where the results could be located was not found on the Garden Terrace Unit . The Unit is separated by a locked dementia care unit from the other part of the building where the survey result was located. The lack of posting or placement of the most recent survey book for the Garden Terrace Unit was confirmed by the Admissions Coordinator on 02/22/12 at approximately 2:00pm. | 2016-02-01 |
| 8696 | 8696 | LAUREL BAYE HEALTHCARE OF GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2011-10-19 | 156 | B | 0 | 1 | PK5911 | On the days of the survey, based on record review and interview, the facility failed to provide 2 of 3 Medicare Provider Non-Coverage notices timely. The findings included: An interview on 10/18/11 at approximately 10:50 AM with the Business Office Manager revealed 2 of 3 Medicare Non-Coverage Notices were not submitted within the required 48 hour requirement. Resident B services ended 7/18/11 and resident was notified on 7/18/11. Resident C had been scheduled to terminate services on 8/2/11. However, the resident had change in condition and remained covered until 8/21/11 when services and coverage ceased.with no notification provided. | 2015-12-01 |
| 8952 | 8952 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2012-05-30 | 160 | B | 0 | 1 | 7U6B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on review of resident funds, interview and review of the facility's policy Resident Trust Accounts, the facility failed to convey funds to the individual or probate jurisdiction administering the resident's estate. The facility conveyed the funds to the facility for Resident A. (1 of 5 resident records reviewed for conveyance of funds.) The findings included: On [DATE], 5 randomly selected residents were reviewed for conveyance of Trust Account Funds. Review of the Resident Trust Fund Account for Resident A revealed that the balance in the resident trust account, $110.00, had been conveyed to the facility. Resident A expired on [DATE] and a check dated [DATE] was issued to the facility. The Business Office Manager confirmed the check had been written to the facility and stated that the resident's representative had authorized the payment to the facility. She verified that the authorization was obtained after the resident's death. She further stated she thought that the resident's representative could authorize the conveyance based on the authorization signed by the daughter at the time of admission which conveyed any refunds, funds and other property held in trust to the daughter, the resident's Power of Attorney. The Business Office Manager also confirmed that she was aware that the Power of Attorney expired with the resident's death. Review of the facility's policy, Resident Trust Accounts, revealed the following statement: Upon a resident's death, the funds along with a financial accounting, must be promptly delivered to the individual administering the resident's estate or as designated by the state regulations. Check must be made out to estate of. | 2015-09-01 |
| 8995 | 8995 | OMEGA HEALTH & REHAB OF GREENVILLE, LLC | 425060 | 809 LAURENS ROAD | GREENVILLE | SC | 29607 | 2011-05-24 | 160 | B | 0 | 1 | ZFEO11 | On the days of the survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate for 2 of 5 random sampled residents. Two residents' funds were conveyed to funeral homes. The findings included: An interview on 5/29/11 at approximately 8:20 AM with the Business Office Manager revealed that 2 of 5 random sampled residents' funds reviewed were conveyed to funeral homes. The Business Office Manager confirmed the findings and further stated the facility did not obtained a signed document/authorization from individual or probate jurisdiction administering the resident's estate to send the funds directly to the funeral home. | 2015-08-01 |
| 9424 | 9424 | LAKE MOULTRIE NURSING HOME | 425341 | 1038 MCGILL LANE | SAINT STEPHEN | SC | 29479 | 2011-03-09 | 159 | B | 0 | 1 | 81IK11 | On the days of the Recertification Survey, based on record review and interviews, the facility failed to obtain authorization to manage personal funds for 2 of 3 residents reviewed with Trust Fund Accounts. The findings included: On 3/9/11 at approximately 11:10 AM, review of resident Trust Account Funds revealed two of three residents did not have signed authorizations in their record for the facility to manage their Trust Fund Account. Resident #14's file contained no documentation which indicated authorization had been granted to the facility to handle personal funds. Resident #A had a Resident's Informed Consent, Authorization and Release Agreement dated 2/14/11 which also indicated no authorization had been granted to the facility to handle personal funds. Review of the Trust Fund Account Balance report indicated Resident #14 had a balance of $30.05 in the account and Resident #A had an account balance of $90.01. During an interview on 3/9/11, the Nursing Home Administrator (NHA) and the Chief Operations Officer (COO) stated they did not know why the residents would have funds on deposit unless the resident or family requested the facility to manage the residents' funds. The NHA and COO confirmed that both residents had money deposited in a trust account and that neither resident, or their legal representative, had provided written authorization to manage the funds. | 2015-05-01 |
| 9425 | 9425 | LAKE MOULTRIE NURSING HOME | 425341 | 1038 MCGILL LANE | SAINT STEPHEN | SC | 29479 | 2011-03-09 | 160 | B | 0 | 1 | 81IK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interviews, the facility failed to convey funds deposited with the facility to the estate of the resident or to the probate court for 2 of 5 residents reviewed for conveyance of funds. The findings included: On [DATE] at approximately 10:30 AM, review of 5 randomly selected residents for conveyance of Trust Account Funds revealed 2 residents with funds on deposit with the facility that were conveyed to the facility. Resident B expired [DATE] and had a balance of $20.00 in a trust account at the time of death. The facility issued a check dated [DATE] to the facility to offset money owed to the facility. Resident C expired on [DATE] and had a balance of $90.03 in a trust account. No check was issued to close the account. During an interview at approximately 11:00 AM on [DATE], the Administrative Assistant who managed the accounts stated that the funds for Resident C had been transferred from the Trust Account to the facilities bank account. The Chief Operations Officer and the Administrative Assistant stated they thought they could close out a resident's Trust Account and pay any balance in the account to the facility if the resident owed money to the facility. | 2015-05-01 |
| 9584 | 9584 | KINGSTREE NURSING FACILITY | 425117 | 401 NELSON BOULEVARD | KINGSTREE | SC | 29556 | 2010-10-13 | 156 | B | 0 | 1 | M1ZN11 | On the days of the survey, based on record review and interview, the facility failed to provide documentation of the timely notification of Medicare Provider Non-Coverage (CMS Form ) for 1 of 3 residents reviewed (Resident A). In addition, the facility failed to provide the required Liability Notice to 2 of 3 residents reviewed (Resident A and Resident #4). The findings included: Review of Notices of Medicare Non-Coverage for Resident A on 10/12/10 revealed the Centers for Medicare and Medicaid Services (CMS) Form indicated that current Skilled Services would end on 8/26/10. Review of the form revealed no resident or representative (RP) signature and no documentation to indicate when/how the resident or RP was notified of this change. In addition, CMS dated 8/16/10 was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. Review of Resident #4's Notice of Medicare Non-Coverage revealed CMS was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. During an interview on 10/13/10 at approximately 10:30 AM, a member of the facility's business staff reviewed the forms for Resident A and Resident #4 and confirmed the above findings. | 2015-03-01 |
| 9679 | 9679 | HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA | 425289 | 1800 EAGLE LANDING BLVD | HANAHAN | SC | 29406 | 2011-02-03 | 159 | B | 0 | 1 | 5MWX11 | On the days of the survey, based on record reviews and interviews, the facility failed to maintain a petty cash fund that was available to the residents seven days a week. The findings included: On 2/2/11 at 4:30 PM a review of the resident funds was done with the facility Payroll Clerk/ Human Resources Assistant. During the review, when asked how the petty cash for the residents was handled, she stated that the residents would come to her office and get the money that they needed. When asked if the funds were available on the weekends she stated no and that she had been employed at the facility for eleven years and there had never been a petty cash fund. During a review with the Administrator on 2/2/11 at 5:10 PM, he stated that there had never been a request for petty cash on the weekends except for about a year ago. He stated he just happened to be in the building on a weekend and a resident asked for cash from the petty fund and he was in the building to give it to him. He further stated that he was on call 24 hours a day, seven days a week and the staff knew that he would come in to get funds from the safe. When asked if that was posted in writing so all staff would know that process. the Administrator stated no. | 2015-01-01 |
| 9885 | 9885 | LAUREL BAYE HEALTHCARE OF WILLISTON LLC | 425297 | 5721 SPRINGFIELD HWY | WILLISTON | SC | 29853 | 2011-07-27 | 159 | B | 0 | 1 | 8DSB11 | On the days of the Recertification Survey, based on record review and interviews, the facility failed to obtain authorization to manage personal funds for 1 of 3 residents reviewed for Trust Fund Accounts. The finding included: On 7/27/11 at approximately 10:55 AM, an expanded review of resident Trust Account Funds revealed Resident B did not provide written authorization to the facility to manage personal funds. The Resident Trust Fund Authorization form from the resident's financial record was blank and unsigned and was confirmed at that time with the Business Office Manager and the Regional Field Analyst. | 2014-10-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );