cms_SC
Data source: Big Local News · About: big-local-datasette
10,300 rows sorted by address descending
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address ▲ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3310 | 3310 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 550 | G | 1 | 0 | QB4N11 | > Based on review of facility files and interview, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside the facility. Resident #1 was held down and his/her fingernails cut when s/he resisted care. LPN (Licensed Practical Nurse) #1 removed the resident from the unit dining room into the hallway outside the dining room and proceeded to cut the resident's nails even though s/he resisted. One of three resident's reviewed for dignity. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA (Certified Nursing Aide) #1, and CNA #2. The facility's details of the reportable incident indicated the DON (Director of Nursing) was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed br… | 2020-09-01 |
| 3311 | 3311 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 600 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair … | 2020-09-01 |
| 3312 | 3312 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 607 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation… | 2020-09-01 |
| 3313 | 3313 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 608 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that ensure each individual reported immediately, but not later than 2 hours after forming the suspicion, for events that cause the suspicion result in serious bodily injury to the State Agency and law enforcement. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was held down by CNA #1 and CNA #2 so that LPN #1 could cut the resident's finger nails. The resident's fingers were nicked during the incident and the resident sustained [REDACTED]. One of two reportable incidents reviewed. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed the incident involving Resident #1 occurred on 1/8/18 at 1:30 PM. Review of the facility's investigation revealed the police were notified on 1/10/18 The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more th… | 2020-09-01 |
| 3314 | 3314 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 609 | D | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Agency. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The incident was not reported within 2 hours to the State Agency. One of two reportable incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands i… | 2020-09-01 |
| 3315 | 3315 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 610 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to prevent further potential abuse and neglect while investigations were in progress and when an alleged violation was verified failed to take appropriate corrective action. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being … | 2020-09-01 |
| 3316 | 3316 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 656 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was noted to have the behavior of refusing care. Resident #1's care plan was not followed related to how staff should respond to the resident's behavior. Resident #2's care plan was not followed by CNA #3. Resident #2 was noted to require 2 staff for ADL care and CNA #3 provided care to the resident without additional staff and heard a pop sound while providing care to the resident. Two of three residents reviewed for care. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident co… | 2020-09-01 |
| 3317 | 3317 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-02-14 | 658 | G | 1 | 0 | QB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to provide services that meet professional standards of quality. CNA (Certified Nursing Aide) #3 heard a pop sound from Resident #2 while providing ADL care. The CNA reported the incident to the resident's nurse. The nurse failed to document the incident in the resident's medical record. Resident #1 was held down by LPN #1 and CNA #1 and #2 and his/her fingernails cut when s/he resisted care. Two of three residents reviewed for professional standards. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident complained of pain in the left arm when touched. This is when the nurse practitioner was asked to see the resident and s/he ordered an x-ray. After consulting with the medical director, it was … | 2020-09-01 |
| 3318 | 3318 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2017-02-23 | 332 | D | 0 | 1 | BE5V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 25 opportunities for error, resulting in a medication error rate of 8%. The findings included: Error#1 On 2/22/17 at 9:17 AM, during observation of Resident #122's medication administration, Registered Nurse #2 was observed to administer 1 spray of [MEDICATION NAME] 50 microgram (mcg.) nasal spray to the resident in each nostril. Following the observation a review of Resident #122 physician's orders [REDACTED]. RN #2 verified s/he only gave 1 spray and the order was for 2 sprays into each nostril. Error #2 On 2/22/17 at 1:07 PM, during observation of Resident #3's medication administration, Licensed Practical Nurse (LPN) #1 administered 1 drop of Artificial Tears 1.4 % eye drops into each of the residents' eyes. On 2/23/17 at 8 :45 AM, reconciliation review of Resident #3's medication administration revealed the physician order [REDACTED]. to Adm: 2 Drops; ophthalmic Spec. Inst: Instill 2 drops in both eyes TID. For dry eyes TID- three times A Day 06:00 AM, 01:00 PM, 08:00 PM. On 2/23/17 at 9:00 AM, LPN #2 verified the physicians order for Resident #3 to receive 2 drops of Artificial Tears 1.4% Solution into both eyes. LPN #1 further stated, We only give one drop per eye on all eye drops. | 2020-09-01 |
| 3319 | 3319 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2017-02-23 | 425 | D | 0 | 1 | BE5V11 | Based on observations, interview, and review of the facility policy, the facility failed to follow a procedure to ensure biologicals and pharmaceutical services met the needs of the residents for 1 of 5 carts reviewed for medication labeling. Eye drops were being used and not labeled properly. The findings included: On 2/23/17 at 9:00 AM, an observation of the 300 unit medication cart with Licensed Practical Nurse #2 revealed Resident #3's Artificial Tears Solution with stamped pharmacy box instructions stating, Artifi Tears Sol 1.4% OP Instill 1 Drop into Both Eyes Three Times Daily for Dry Eyes. Also, review of Resident #3's physicians orders revealed an order stating, Artificial Tears (polyvinyl alcohol) (OTC) drops; 1.4% Amt. to Adm: 2 Drops; ophthalmic Spec. Inst: Instill 2 drops in both eyes TID. For dry eyes TID- three times A Day 06:00 AM, 01:00 PM, 08:00 PM. Following the review of the pharmacy box instructions and the physicians' orders with LPN #2, s/he verified there was a discrepancy in the physicians order for the Resident #3 to receive 2 drops of Artificial Tears Solution into both eyes and the pharmacy stamped box instructions that stated to instill 1 drop into both eyes. Review of the facility policy Storage of Medications, revealed under (3.) Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for labeling before storing. | 2020-09-01 |
| 3320 | 3320 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2019-05-02 | 812 | E | 0 | 1 | 2VSL11 | Based on observation, interview, and review of the facility's policy titled Handling Cold Foods for Trayline, the facility failed to ensure that foods were held at the correct temperature before serving. Tuna salad on lettuce was not held at a temperature of 41 degrees or cooler in 1 of 3 dining rooms observed with food served in the dining room. The findings included: On 05/01/19 at 12:04 PM, observations of food temperatures revealed one tuna salad on top of lettuce that had a temperature of 48.3 degrees sitting on top of ice in a plastic tub. The Dietary Aide and the Dietary Technician were both aware of the temperature of the tuna salad. The Dietary Technician instructed the Dietary Aide to place the salad back on the ice. At 12:34 PM, the Dietary Aide plated an item from the tray line and a Certified Nursing Assistant picked up the tuna salad and placed it on the tray to be served. Delivery of the tray was stopped by the surveyor. During an interview at that time, the Dietary Technician confirmed the temperature had been 48.3 degrees. When asked, the Dietary Technician knew the tuna salad had to be maintained at a temperature of 41.0 degrees or less and had not stopped the Dietary Aide from placing the salad on a tray to be served. Review of the facility's policy titled Handling Cold Foods for Trayline, revealed 3. Cold temperatures will be taken and recorded prior to and halfway through service to assure foods are (less than or equal to) 41 (degrees) F (Fahrenheit). | 2020-09-01 |
| 3321 | 3321 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2019-05-02 | 867 | D | 0 | 1 | 2VSL11 | Based on interview and review of the facility's documentation, the facility failed to monitor results of a Performance Improvement Plan (PIP) to determine if changes were effective at ensuring foods were at the appropriate holding temperature or if the interventions should be revised. The findings included: On 05/02/19 at approximately 02:45 PM, the Nursing Home Administrator (NHA) provided a PIP (Performance Improvement Plan) related to recording of food temperatures and ensuring they were within regulations. Further review revealed the PIP was documented as completed on 03/29/19. Other issues also identified related to food service included in the PIP were documented as completed on 04/04/29. During an interview on 05/02/19 02:53 PM, the Nursing Home Administrator (NHA) confirmed the PIP was completed and that there was no plan in place for monitoring to ensure continued compliance. The NHA confirmed the PIP had been ineffective. | 2020-09-01 |
| 3322 | 3322 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 623 | F | 0 | 1 | 2M9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident's #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was notified of the transfer to the hospital as soon as practicable. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided written notification to the resident/ Resident's Representative of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not given written notification to the RR. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident's Responsible Pa… | 2020-09-01 |
| 3323 | 3323 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 625 | F | 0 | 1 | 2M9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the Bed Hold Policy to the resident/ resident representative for Resident #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was provided the Bed Hold Policy at the time of transfer to the hospital. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided the Bed Hold Policy to the resident/ Resident's Representative at the time of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not sent the Bed Hold Policy when someone goes to the hospital. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident'… | 2020-09-01 |
| 3324 | 3324 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 760 | E | 0 | 1 | 2M9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy and manufactures recommendations, the facility failed to administer the correct amount of medication resulting in significant medication error for 1 of 2 residents reviewed for insulin medication administration. Resident # 62 did not receive the correct amount of insulin. The findings included: On [DATE] the facility admitted Resident #62 with a [DIAGNOSES REDACTED]. On [DATE] at 2:35 PM, an observation of the 200 unit rehab cart with LPN #1 revealed; Resident #62 had (1) open vial of Humalog insulin (Lot #C 7A) (,[DATE] remaining) with a puncture date of ,[DATE] and (1) open vial of [MEDICATION NAME] (Lot #7F015B) (,[DATE] remaining) with a puncture date of ,[DATE] and a hand written expiration date of [DATE] on the box. LPN #1 verified the Humalog and [MEDICATION NAME] were expired and indicated the insulin should have been removed from storage. On [DATE] at 3:00 PM, a review of Resident #62's Medication Administration Record [REDACTED]{(3) doses on [DATE], (1) dose on [DATE], (2) doses on [DATE], and (1) dose on [DATE]} of Humolog insulin and (3) doses {(1) dose on [DATE], (1) dose on [DATE], and (1) dose on [DATE]}of [MEDICATION NAME] after the expiration date. LPN #1 verified the Humalog and [MEDICATION NAME] vials were in-use after the expiration date. Review of the facility policy, Administering Medication, reveals under (9.) The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Review of the Humalog manufactures recommendations reveals under 16.2 Storage and Handling states, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be discarded, even if they still contain Humalog. Review of… | 2020-09-01 |
| 3325 | 3325 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 761 | E | 0 | 1 | 2M9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the facility policy, and review of the Humalog and [MEDICATION NAME] manufactures package insert instructions, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 5 medication storage carts reviewed. Expired medication (insulin) was on the 200 unit rehab cart after the manufactures recommended expiration date. The findings included: On 5/14/18 at 2:35 PM, an observation of the 200 unit rehab cart with LPN #1 revealed, (1) open vial of Humalog insulin (Lot #C 7A) (1/2 remaining) with a puncture date of 4/13 and (1) open vial of [MEDICATION NAME] (Lot #7F015B) (1/3 remaining) with a puncture date of 4/13 and a hand written expiration date of 5/11/18 on the box. LPN #1 verified the Humalog and [MEDICATION NAME] were expired and in-use, and indicated the insulin should have been removed from storage. Review of the facility policy, Storage of Medications, revealed under procedure (K.) Medications requiring stored in refrigerator until opening are kept in cart at room temperature once refrigerator medication has been opened. Each opened box shall be dated when opened, have beyond use date, and have nurse's initials. Refer to manufactures recommendations for use of storage date once refrigerator product has been opened and stored on cart. Also procedure (N.) states, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. Review of the Humalog manufactures recommendations reveals under 16.2 Storage and Handling states, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be… | 2020-09-01 |
| 3326 | 3326 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 812 | F | 0 | 1 | 2M9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens reviewed and has the potential to affect 69 of 69 residents with ordered diets as evidenced by failing to do the following: Air dry pans, dispose of expired food, plate food sanitarily, and clean (hood, oven, fans, floors, ice scoop holder, microwave, can opener). The findings included: On [DATE] at 10:25 AM, an initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed: 1.) (6) 2 inch shot gun pans, (9) ,[DATE]th pans, and (4) ,[DATE] pans stacked wet in clean pan shelf. 2.) The hood above the stove and ovens was dripping grease behind the cooking line onto a motor of the convection oven which also had a build-up of dust. Furthermore, one of the hoods grease catch pans was over flowing with grease. The CDM stated an outside service cleaned the hood every (3) months. (MONTH) of (YEAR) was the last service date recorded on a sticker attached to the hood. 3.) The ice scoop holder did not have drainage and had black/white debris floating and growing in the water at the bottom. 4.) Standup refrigerator had (1) 64 ounce bulk container of Franks Red Hot sauce with a best by date of (MONTH) 19, (YEAR) that was half full. 5.) Walk-in refrigerator had (7) bundles of Asparagus without an expiration date that had a white fuzzy substance growing on them. 6.) Dry storage room had (6) heads of Cabbage that were rotten with brown discolored leaves and was dripping a brown malodorous liquid onto the floor, furthermore, (5) flies were on and around the cabbage. 7.) (1) Fan in the main kitchen had a build-up of dust, also the walk-in refrigerator (3) fans had a build-up of a white fuzzy substance growing and was blowing onto the food. 8.) Microwave in main kitchen had food build-up on the door, and food spillage/spatter inside. 9.) Oven doors and oven interior in m… | 2020-09-01 |
| 3327 | 3327 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 814 | D | 0 | 1 | 2M9S11 | Based on observations, interview, and review of the facility's policy, the facility failed to dispose of garbage and refuse properly for 1 of 1 refuse container area reviewed for garbage disposal. Trash and grease were not contained in refuse containers leaving grease, trash, and medical waste visible. The findings included: On 5/14/18 at 1:00 PM, an observation of the dumpster area and grease container outside behind the kitchen revealed 8 plastic bottles, 4 boxes, 2 bags of trash, food wrappers, and (2) blue medical gloves on the ground behind and between the dumpster's. Also, the grease container was on uneven pavement and had spillage/black substance (2 feet by 4 feet) leaking onto the pavement which was emptying into a ground water drain on the pavement. On 5/15/18 at 11:00 AM, an observation with the Certified Dietary Manager (CDM) of the dumpster area and grease container outside behind the kitchen revealed 8 plastic bottles, 4 boxes, 2 bags of trash, food wrappers, and (2) blue medical gloves on the ground behind and between the dumpster's. Also, the grease container was on uneven pavement and had spillage/black substance (2 feet by 4 feet) leaking onto the pavement which was emptying into a ground water drain on the pavement. On 5/15/18 at 11:05 AM, during an interview, the CDM verified the grease and debris on the ground near the dumpster's and grease container area, s/he further indicated that no debris or grease should be on the ground. Review of the facility policy, Left over grease refuse, Dumpster area stated, It is the policy that the area for this storage area to stay neat and clean of all refuse rather it be grease on the ground or trash in the dumpsters. Procedure: On a daily basis, as food service personnel or any other personnel who take out trash to recognize spillages and report them to Food service operation for immediate cleanup. Upon recognition, the Food service staff are to clean these areas. | 2020-09-01 |
| 3328 | 3328 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 880 | D | 0 | 1 | 2M9S11 | Based on observations, interview, review of the facility policy and the Center for Disease Control Prevention safety recommendations, the facility failed to follow a procedure to ensure precautions were observed for the disposal of contaminated equipment for 1 of 1 resident observed for finger stick blood sugar. A Finger stick device was not disposed of in an approved sharps container on the 300 unit. The findings included: On 5/15/18 at 11:36 AM, during an observation of Resident #25's med pass on the 300 unit, Licensed Practical Nurse (LPN) #2 used a finger stick device to penetrate the residents' finger to produce blood to monitor the residents' blood sugar. LPN #2 then placed the finger stick device into the general trash can on the medication cart. There was a sharps container on the medication cart. Following the observations LPN #2 verified the finger stick device was placed into the general trash and indicated that the device should have been placed into the sharps container on the cart. Review of the facility policy, Blood Sampling - Capillary (Finger Sticks) states, under Steps in the procedure (.7) Discard lancet and platform into the sharps container. Review of the Center for Disease Control Prevention recommendations revealed under Infection Prevention during Blood Glucose Monitoring and Insulin Administration, section Blood Glucose Monitoring, Fingerstick Devices bullet #2 states, Dispose of used lancets at the point of use in an approved sharps container. Never reuse lancets. | 2020-09-01 |
| 3329 | 3329 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2018-05-17 | 908 | D | 0 | 1 | 2M9S11 | Based on observation, interview, and facility policy, the facility failed to maintain equipment in a safe operating condition for 1 of 1 convection ovens reviewed. The convection oven in the main kitchen had a large build-up of grease and dust on the motor. The findings included: On 5/14/18 at approximately 10:25 AM, during initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed the motor in the rear of the convection oven had a large build-up of dust and grease which was dripping from the hood above. The grease was draining into the vents of the rear of the motor. The CDM verified the heavy build-up of grease and dust and was asked if the hood and ovens were on a cleaning schedule. The CDM stated, The hood is on a 3 month cleaning schedule from an outside contractor. Following the observation of the grease dripping from the hood and interview with the CDM, another observation of the hood revealed a contractor sticker indicating (MONTH) (YEAR) as the last cleaning date of the hood. The CDM verified the contractor sticker indicating (MONTH) (YEAR) as the last service date. Review of the facility policy,[NAME]Cleaning stated, Hoods are to be cleaned by a contractor trained in professional hood cleaning on a 6 month basis. | 2020-09-01 |
| 4877 | 4877 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2016-05-12 | 274 | D | 0 | 1 | LJQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify a significant change in status and conduct a Significant Change in Status Assessment as required for Resident #18, 1 of 3 residents reviewed with a change in status. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. At 11:21 AM on 05/11/2016, Review of the MDS (Minimal Data Set) revealed Resident #18 had a significant change in status on a 4/10/16 Quarterly Assessment when compared to the Admission assessment dated [DATE]. Improvement was noted in cognition from a staff assessment of short and long term memory problems and rarely making decisions to having a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. Resident #18 was also noted to have an improvement in verbal behaviors and eating went from extensive assistance to supervision. The resident also was noted to have a decline in mood from a staff assessment of mood indicators with a score of 1 to a resident interview with a score of 5 and a decline in ambulation from limited assistance to activity did not occur At 11:42 AM on 05/11/2016, review of the Progress Notes revealed a note dated 4/21/16 by Social Services that Resident #18 had improved cognitively overall. Further review revealed no documentation by nursing that the resident had improved performance in ADLs (Activities of Daily Living). During an interview on 05/12/2016 at 4:07 PM, the RN (Registered Nurse) MDS Coordinator confirmed Resident #18 had improvements in cognition, behaviors, and eating and a decline in mood and ambulation. The MDS Coordinator stated that s/he was not responsible for doing sections C (Cognition) or D (Mood) but confirmed that s/he was responsible for coordinating the assessment and that a Significant Change in Status Assessment should have been done. | 2019-07-01 |
| 4878 | 4878 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2016-05-12 | 279 | D | 0 | 1 | LJQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify the risk for weight loss or develop a comprehensive care plan for actual weight loss for Resident #114, 1 of 4 residents reviewed for nutrition. The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. At 3:13 PM on 05/12/2016, review of the Weight records revealed the resident had an admission weight on 4/08/16 of 105.7 pounds. On 4/13/16 the weight was recorded as 103.0 pounds, on 4/18/16 98.5 pounds, on 4/19/16 98.9 pounds , on 4/25/16 95.1 pounds, and on 4/27/16 94.7 pounds. The resident had a total weight loss of 11.0 pounds, a significant loss of 10.4% At 4:29 PM on 05/12/2016, review of the care plan revealed no care plan for nutrition, potential or actual weight loss. During an interview on 05/12/2016 at 5:02 PM, the RN (Registered Nurse) MDS Coordinator confirmed Resident #114 had a significant weight loss. The RN further stated that the resident's weight loss had not been discussed at the weekly risk meeting until 5/5/16 and that there was no care plan for nutrition, potential or actual weight loss. | 2019-07-01 |
| 5987 | 5987 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 157 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the physician of changes in residents conditions potentially requiring physician intervention for 1 of 1 sampled resident reviewed with orders for TED ([MEDICAL CONDITION]-deterrent) hose. Staff failed to notify the attending physician that Resident #8 suffered from [MEDICAL CONDITION] and refused to wear TED hose as ordered. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:51 PM, record review revealed an order for [REDACTED]. At 4:55 PM on 1/12/15, observation revealed the resident was not wearing the TED hose. On 1/13/15 at 8:50 AM, observation revealed the resident was out of bed, dressed, and was not wearing the TED hose. At 10:43 AM on 1/13/15, record review revealed Telephone Orders dated 11/24/14 for T-Hose on in morning, T-Hose off (at) HS (bedtime), 12/17/14 for TED Hose, and 12/22/14 for Clarification TED Hose on in am, off at HS Apply to bilateral LEs (lower extremities). Review of the Telephone Orders also revealed an order dated 12/11/14 Set up appt (appointment) .Cardiology Dx (diagnosis) new [MEDICAL CONDITION]. Review of the Doctor's Progress Notes revealed a 12/11/14 note that stated .Leg swelling not much improved .Ext: (Extremities) [MEDICAL CONDITION] 2+ R (right) 1+ L (left) .Ted hose in place. The note further stated the assessment and plan were Dependent [MEDICAL CONDITION] - (check) ECHO (echocardiogram) (check) BNP (brain natriuretic peptide) Send to .Cardiologist. A progress note dated 12/17/14 from the Cardiologist was reviewed that stated Pt (patient) has swelling R >> (greater than) L .Needs TED Hose. Review of the Treatments Administration History on 1/14/15 at 9:10 AM for 12/22/14 through 1/13/15 revealed Resident #8 refused to wear the TED hose on 12/22/14 and 12/23/14 and notified MD (Medical Doctor) to advise dated 12/22/14. Review of history also revealed the TED hose were signed off daily… | 2018-07-01 |
| 5988 | 5988 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 244 | E | 0 | 1 | 9JKN11 | Based on observations, interviews and review of the facility's policy entitled Dietary Services and the facility's documented meal service times, the facility failed to act upon grievances voiced by residents as stated in the group interview. Three of 5 residents in attendance stated that meals were served at least one (1) to one and one-half (1 1/2) hours late for at least one meal each day. One anonymous resident/family and one of four residents selected for individual interviews (Resident #9) complained of meals being served late. Meals were also observed to be served late in 1 of 3 dining areas. The findings included: A Group Interview was conducted with five residents on 1/13/15 at approximately 10:30 AM. Three of the five residents in attendance stated that meals were served at least one (1) to one and one half (1 1/2) hours late for at least one (1) meal each day, usually dinner. Two (2) of the residents were from Unit 2 and one (1) from Unit 1. One (1) resident from Unit 2, stated that s/he no longer ordered the alternate meal due to the meal consistently being served after s/he had gone to bed. When asked by the surveyor if they had spoken with anyone at the facility or filed a grievance, each of the three stated that they had spoken to the dietary manager on multiple occasions and had seen no change in the service times. One resident stated that this had been brought to the facility's attention as far back as (MONTH) 2014. Review of the meal times provided by the facility indicated that dinner should be served by .5:45 PM on Unit 1 and 6:00 PM on Unit 2. The facility's Dietary Services Policy stated that the meal service times were: .Breakfast 8:00 AM, Lunch 12:00 PM and Dinner 6:00 PM . During an interview prior to entering the facility for survey, the Ombudsman stated that a concern had been voiced by a family member and/or resident who wished to remain anonymous related to trays being served and residents being fed late. During the initial tour of Unit 2 on 1-12-15 at approximately 4:00 PM, Resident … | 2018-07-01 |
| 5989 | 5989 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 278 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that 2 of 12 sampled residents were accurately assessed. Resident #4 had inconsistent coding of communication and cognitive status on the Minimum Data Set (MDS) Assessment. Psychiatric [DIAGNOSES REDACTED].#11. The findings included: Record review on 1-14-15 at approximately 10:15 AM revealed that Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 10-26-14 Quarterly MDS Assessment revealed that these [DIAGNOSES REDACTED]. During an interview on 1-14-15 at approximately 12:00 PM, the MDS Coordinator confirmed that the psychiatric [DIAGNOSES REDACTED]. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 1/13/15 at approximately 2:13 PM, review of the Minimal Data Set (MDS) assessment dated [DATE] revealed the resident was coded as understood and usually understands in Section B related to communication. Further review revealed that the question Should Brief Interview for Mental Status (BIMS) be Conducted? was answered No. (resident is rarely/never understood). Continued review of Section C revealed that the staff interview had been conducted regarding the resident's cognitive status instead of attempt made to conduct the resident interview (BIMS). The resident was coded as having short term and long term memory problems and Cognitive Skills for Daily Decision Making was coded as Severely Impaired - never/rarely made decisions. During an interview on 1/14/15 at 10:15 AM, the MDS Coordinator confirmed that the coding of communication on the MDS was inconsistent with the coding of the resident's cognitive status for completion of the BIMS. | 2018-07-01 |
| 5990 | 5990 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 279 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop comprehensive care plans that include measurable goals and objectives with interventions to address care and services for medical and nursing needs for 2 of 9 sampled residents reviewed for care plan development. The care plan for Resident #5 did not address Diabetes Mellitus, pain, fall risk, use of safety devices, or psychoactive medication use. The care plan for Resident #8 did not address Hypertension, diuretic therapy, psychoactive medication, Vascular Insufficiency or the presence of a lower extremity wound. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:36 PM, record review revealed monthly cumulative Physician order [REDACTED]. On 1/14/15 at 9:40 AM, review of the physician's orders [REDACTED]. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 6:10 PM, review of the monthly cumulative Physician order [REDACTED]. On 1/14/15 at 1:25 PM, review of the care plan revealed no identified problem areas with planned interventions for depression with administration of psychoactive/antidepressant medication. The resident's Hypertension, potential for dehydration related to diuretic therapy, potential for falls, the use of safety devices, the [DIAGNOSES REDACTED]. During an interview on 1/14/15 at 3:40 PM, the Minimal Data Set Coordinator reviewed the comprehensive care plan for Resident #5 and confirmed that it did not address Diabetes or FSBS, pain, fall risk and use of safety devices, or psychoactive medication. The MDS Coordinator further confirmed the care plan for Resident #8 did not address Hypertension, potential for dehydration, psychoactive medication use, or the right lower extremity wound. | 2018-07-01 |
| 5991 | 5991 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 280 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and update the care plans to reflect the current status of 4 of 12 sampled residents reviewed for revision of care plans. Resident #5's care plan was not updated after an anticoagulant was discontinued. Resident #8's care plan was not updated after a fall or to address new onset of [MEDICAL CONDITION] and refusal of treatment. Resident #12's care plan was not updated after conversion to hospice. Resident #13's care plan did not address placement of a WanderGuard bracelet as an approach for exit seeking behavior. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Record review on 1/14/15 revealed an 8/13/13 physician's orders [REDACTED]. An interview at 4 PM on 1/14/15, Registered Nurse (RN) #3 confirmed that Resident #13 did have a WanderGuard on his/her right wrist and that s/he checked the function of the WanderGuard each shift. The nurse reviewed the care plans for Resident #13 and confirmed there was no care plan for the WanderGuard, how often it should be checked for placement and function, or when it should be replaced. A review of Resident #12's record for Hospice Care was conducted on 1/14/15 at approximately 9:55 AM. The facility's care plan had been updated on 10/30/14 to include Resident appears to be near the end of life with obvious health decline. On 10/31/14 the resident was admitted to Hospice Care. The facility's care plan for Resident #12 contained no update to include Hospice Care. On 1/14/15 at approximately 11:45 AM, during an interview with the Minimum Data Set (MDS) Coordinator, s/he verified that the facility had not updated the resident's care plan to include Hospice and stated that s/he was not aware that it should be updated when a change of condition assessment was done for Hospice. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the care plan on 1/14/15 at 1:25 PM revealed a problem dated 5/… | 2018-07-01 |
| 5992 | 5992 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 281 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the American Journal of Nursing, (MONTH) 2007, the facility failed to accurately document treatment application for one of one resident reviewed with orders for TED ([MEDICAL CONDITION] deterrent) hose. The nurse initialed that TED hose were applied to Resident #8 when they were not observed to be on the resident for two consecutive days of the survey. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:51, record review revealed an order for [REDACTED]. On 1/13/15 at 8:50 AM, observation revealed the resident was out of bed and dressed and was not wearing the TED hose. Review of the Treatments Administration History on 1/14/15 at 9:10 AM revealed the TED hose were signed off daily on 1/12 and 1/13/15 AM shift as being applied and removed though observation revealed the resident was not wearing the hose on 1/12 or 1/13/15. During an observation and interview on 1/13/15 at 5:10 PM, Licensed Practical Nurse (LPN) #2 confirmed on observation that the resident was not wearing the TED hose. The LPN asked the resident if they (Certified Nursing Assistants) were putting them on and the resident stated No. The LPN also confirmed the staff had signed off the TED hose on 1/12/15 and 1/13/15 and that s/he had observed the resident on 1/13/15 without the hose. Review of the American Journal of Nursing, (MONTH) 2007, pages 58-60, revealed the following: Regardless of the practice setting, nurses must preserve the integrity of the record in the following ways. Accurate and complete patient information must be entered on all paper and electronic documentsDocumentation should include completed treatments, procedures, .as well as those that have not been completed and the reason they were not completed. | 2018-07-01 |
| 5993 | 5993 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 371 | E | 0 | 1 | 9JKN11 | Based on observations and interviews, the facility failed to maintain the cleanliness of resident-use refrigerators on 3 of 3 units. Each had dried food/liquid spills in the unit, scattered debris, black substance on the door seal, and/or cracked/broken seal around the door. In addition, based on observation and interview, facility staff failed to serve food in a sanitary manner to prevent transmission of disease/infection on 2 of 3 Units during meal observation. 4 staff members were observed handling resident's food with their bare hands. The findings included: On 1/13/15 at approximately 9:40 AM, the resident refrigerator on Unit 1 was observed to have dried spills and debris on the shelves and floor of the unit. This was verified at the time of the observation by Dietary Staff #1. At 10:04 AM on 1/13/15, the Unit 2 resident refrigerator had a thick blackish substance in and on the seal around the door, dried spills and food debris on the shelves and the seal around the door was cracked and torn across the bottom of the door. This was verified at the time of the observation by Certified Nursing Assistant (CNA) #7. At 10:10 AM on 1/13/14, the Unit 3 refrigerator had heavy build up of dried spills on the racks, shelves and door shelves, the floor of the unit and the doors. This was verified at the time of the observation by CNA #8. On 1/14/15 at approximately 10:25 AM, the Unit 3 resident refrigerator had spills and debris in the door shelves, the drawer tracks, solid shelves and seal. The was again verified by CNA #9. The refrigerators on Units 1 and 2 were also unchanged and remained soiled. The maintenance worker observed the seal on the Unit 2 refrigerator and stated they would replace it. A policy was requested to identify staff responsible for maintaining resident refrigerators but was not received. During meal observation on Unit 1 at 6:22 PM on 1/12/15, Certified Nursing Assistant (CNA) #4 was observed to serve 3 residents their evening meals. In each case, the CNA picked up the top of the hamburger bun w… | 2018-07-01 |
| 5994 | 5994 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 496 | D | 0 | 1 | 9JKN11 | Based on personnel record reviews and interview, the facility failed to complete Certified Nursing Assistants (CNA) Registry verification prior to hire for 2 of 2 CNA records reviewed. The findings included: Personnel records for Certified Nursing Assistants A and E were checked on 1/14/15 for Registry verification prior to hire. CNA A was hired 12/11/14. A registry check was done on 10/21/13 but had not been done prior to this rehire date of 12/11/14. CNA E had a hire date of 11/20/14. No registry verification could be located for this CNA prior to hire. At 12:30 PM on 1/14/15, the Administrator reviewed the records and confirmed that registry verifications had not been done for the above staff as noted. | 2018-07-01 |
| 5995 | 5995 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 499 | D | 0 | 1 | 9JKN11 | Based on personnel record reviews and interview, license verification was not completed for 2 of 2 licensed nurses prior to hire. The findings included: Personnel records for Registered Nurse (RN) B, and Licensed Practical Nurse (LPN) D were reviewed on 1/14/15 for license verification prior to hire. Registered Nurse B, with a hire date of 11/10/14, had no license verification in his/her personnel folder. LPN D, with a hire date of 12/12/14, had a license check done on the date of hire and was in the facility for orientation on that date. No evidence was provided that the license was verified prior to the nurse's actual start of work time. At 12:30 PM on 1/14/15, the Administrator reviewed the records and confirmed that license verifications had not been done, or had not been done timely, for the above staff. | 2018-07-01 |
| 5996 | 5996 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 502 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain laboratory (lab) tests as ordered for 2 of 10 sampled residents reviewed for provision of lab services (Residents #4 and #5). The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 1/14/15 at 11:35 AM, review of the laboratory results in the record revealed a Complete Metabolic Panel (CMP) dated 9/9/14 with an elevated Creatinine. On the lab report, the physician/nurse practitioner had written a note to repeat a Basic Metabolic Panel (BMP) in 1 week. Further review revealed no results for a BMP dated 1 week after the CMP. During an interview on 1/14/15 at 11:35 AM, the Interim Director of Nursing confirmed there were no results in the record and at 12:42 PM confirmed that the lab test had not been obtained as ordered. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/12/14 at 5:35 PM, review of the monthly cumulative physician's orders [REDACTED]. Further review revealed an 8/14/14 order for a HGB A1C (glycated hemoglobin test) every 3 months that was scheduled for March, June, (MONTH) and December. On 1/14/15 at 9:40 AM, record review revealed no [MEDICATION NAME] Acid Level result for (MONTH) and no HgbA1c result for December. During an interview on 1/14/15 at 3:21 PM, Licensed Practical Nurse (LPN) #2 confirmed that the [MEDICATION NAME] Acid Level and HgbA1c had not been obtained as ordered. | 2018-07-01 |
| 5997 | 5997 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 504 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility obtained laboratory services (labs) without physician's orders for Resident #5, 1 of 10 sampled residents reviewed for laboratory services. A Comprehensive Metabolic Panel (CMP) and HgbA1c (glycated hemoglobin test) were obtained without physician's orders. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/14/15 at 9:40 AM, record review of the lab results in the resident's record revealed Hgb A1c tests were completed on 9/23/14 and 10/3/14. CMP studies were done on 9/8/14 and 12/2/14. Review of the monthly cumulative Physician's Orders and Telephone Orders revealed the HgbA1c was ordered every 3 months and the CMP was ordered every 6 months (March and September). No telephone orders could be located for the 10/3/14 Hgb A1c or for the 12/2/14 CMP. During an interview on 1/14/15 at 3:21 PM, Licensed Practical Nurse #2 confirmed there were no orders for either test. | 2018-07-01 |
| 5998 | 5998 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 507 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have results of laboratory (lab) tests available for clinical management in the residents' records for 2 of 10 sampled residents reviewed for laboratory services. Resident #1 had lab tests on 10/5/14 and Resident #8 had lab tests on 11/10/14, 12/1/14, and 12/11/14, with no reports found in the residents' records. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/13/15 revealed a 9/4/14 physician's orders [REDACTED]. On 9-5-14, a [MEDICATION NAME] Level was drawn and the result was 10.4 ug (micrograms)/ml (milliliter) H(igh) (reference range of 4.00-10.00 ug/ml). The report stated: Panic result: Call to (Registered Nurse) at 11:23 .read back. A 9/5/14 note on the lab report indicated that the level was to be repeated on 10-4-14. Review of the resident's record revealed no lab result for this date. Interview with Licensed Practical Nurse #1 and Registered Nurse (RN) #2 on 1/14/15 confirmed there was no lab result in the record. RN #2 called the lab and verified that it had been done on 10/3/14 with a Panic result: Call to (RN) at 10:42 .read back. However, s/he confirmed the copy had never been placed in the resident's record. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. The resident was receiving an antibiotic upon admission to the facility. On 1/13/15 at 10:15 AM, review of the Telephone Orders revealed a 11/10/14 order for a [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) laboratory (lab) test, an order dated 11/17/14 to recheck a Magnesium Level in 2 weeks, and an order dated 12/11/14 for a Magnesium Level, BNP (Brain Natriuretic Peptide), [MEDICATION NAME], CBC (complete blood count) and BMET (Basic Metabolic Panel) to be drawn the following morning. Record review revealed none of these lab results were available in the resident's record. On 1/14/15 at 9:42 AM, Licensed Practical Nurse (LPN) #2 confirmed the labs wer… | 2018-07-01 |
| 5999 | 5999 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 513 | D | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain diagnostic reports as required for 1 of 1 sampled residents reviewed with orders for an Echocardiogram. Resident #8 did not have results in the clinical record for an Echocardiogram (ECHO). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/13/15 at 10:15 AM, record review revealed a 12/11/14 Telephone Order for ECHO Dx. (diagnosis) [MEDICAL CONDITION]. Further record review revealed no ECHO results were located in the chart. During an interview on 1/14/15 at 9:10 AM, Registered Nurse #1 confirmed the ECHO results were not in the resident's record. At 9:42 AM on 1/14/15, a copy of the ECHO result was provided by the facility. Licensed Practical Nurse #2 reviewed the result and confirmed it had been received by the facility at 9:30 AM on 1/14/15. | 2018-07-01 |
| 6000 | 6000 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-01-15 | 520 | E | 0 | 1 | 9JKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement an appropriate plan of action to correct identified quality deficiencies in a timely manner related to late and/or missing Minimum Data Set (MDS) Assessments for Residents #3 and #4 and 17 non-sampled residents. The findings included: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/13/15 revealed a Quarterly Assessment had been completed on 4/16/14 and 9/28/14 (greater than 5 months apart). Another assessment was due for 12/28/14. When pulled up on the computer for MDS (Minimum Data Set) the assessment for 12/28/14 read in progress not completed. This was confirmed with the MDS Coordinator. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. On 1/13/15 at 2:13 PM, paper and/or computerized record review for Resident #4 revealed a 9/3/14 Admission Minimum Data Set (MDS) Assessment. Further review revealed a Quarterly Assessment with an Assessment Reference Date (ARD) of 11/26/14 listed as in process in the computer. During an interview on 1/14/15 at 10:15 AM, the MDS Coordinator confirmed the Admission Assessment was the only completed assessment. S/he further confirmed a Quarterly Assessment with an ARD of 11/26/14 had been opened but not completed. The MDS Coordinator provided copies of the MDS assessments for Resident #4 with a note attached that stated, We have previously made a QA (Quality Assessment) for these late assessments and are working towards getting up to date. On 1/14/15 at 12:15 PM, the MDS Coordinator stated s/he had been officially in the position since 10/27/14. The Coordinator stated s/he had identified that there were missing/late assessments at that time and thought s/he could catch them up,but had been unable to do so. The Coordinator further stated s/he probably did not request help at that time but may have mentioned it in passing. The Coordinator stated s/he had reported it to ma… | 2018-07-01 |
| 6001 | 6001 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-07-09 | 226 | D | 1 | 0 | H3LQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. Housekeeper #1 reported an allegation of abuse to the supervisor on duty related to Certified Nurse Aide (CNA) #1's treatment of [REDACTED]. CNA #3, who was present in the room at the time of the incident, failed to report the allegation of abuse. CNA #1 continued to work for the remainder of his/her shift and the incident was not reported to the Health Care Manager, Director of Nursing or Administrator until approximately 2 hours after the initial allegation. One of one residents reviewed for abuse. The findings included: The facility reported an allegation of verbal abuse for CNA #1 directed toward Resident #1. The facility sent the Initial 24-Hour Report form on 6/8/15 for the incident that occurred on 6/5/15 at 1:50 PM. The report indicated the housekeeper overheard CNA #1 making derogatory statements to the resident and reported it. Review of the Timecard Legend revealed CNA #1 worked until 3:10 PM on 6/5/15. CNA #3 was present in the room with CNA #1 at the time of the incident. CNA #3 failed to report the allegation per facility policy. Review of the facility's Time Line of Events for the alleged incident indicated CNA #1 was suspended on 6/6/15. Review of CNA #1's Timecard revealed s/he worked 7:05 AM-3:10 PM on 6/5/15 and 6:57 AM-8:00 AM on 6/6/15. Review of the Registered Nurse (RN) Supervisor's facility-obtained statement dated 6/5/15 indicated Housekeeper #1 told him/her about an allegation of verbal abuse concerning Resident #1 and CNA #1. The RN Supervisor told Housekeeper #1 to write a statement of what occurred. In an interview with the surveyor on 7/7/15 at approximately 1:30 PM, the Unit 1 Manager stated s/he left the facility between 12:30-12:45 on 6/5/15. The DON told him/her about the incident on Monday 6/8/15. The Unit 1 Manager had talked to CNA #1 about his/… | 2018-07-01 |
| 6002 | 6002 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-07-09 | 280 | D | 1 | 0 | H3LQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to periodically review and revise the resident's comprehensive care plan. Resident #1 was noted to have several recommendations from a consultant psychiatrist. The resident's care plan was not updated to reflect the interventions. One of one residents reviewed for care plans. The findings included: Review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Review of the care plan revealed behavioral symptoms, resident keeps his hands in undergarments in public areas, was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to redirect as needed and provide alternative activity if allowed by resident. The care plan indicated all approaches listed had a start date of 3/6/15. There was no reference to medication interventions for Resident #1's behavior. Review of Resident #1's medical record revealed a Psychiatry Note dated 5/8/15. The note had a fax date of 5/12/15 printed on it. The note listed the reason for the consult as resident reportedly locking himself in the bathroom. Resident is masturbating openly in front of others. Staff unable to stop behaviors. The treatment plan and recommendation section of the note indicated will get in contact with nursing home to discuss behavioral modification for masturbating in public, which could be the best intervention. The interventions included using distraction to get the patient's attention to something else, try to avoid friendly touch especially by female staff, try to keep the patient away from other female residents and decrease contact as much as they can, try to control the content seen at the TV for something less stimulating, if patient has to sit in public try to cover the patient with a blanket if this can partially solve the problem. Review of Resident #1's follow-up Psychiatry Note dated 6/23/15 indicated behavioral modifications were discus… | 2018-07-01 |
| 6003 | 6003 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2015-07-09 | 319 | D | 1 | 0 | H3LQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident who displays psychosocial adjustment difficulty received the appropriate treatment and services to correct the assessed problem. Resident #1 was referred to a psychiatrist related to increased behavior. The psychiatrist recommended interventions for the facility to put into place for the resident. The interventions were not reviewed with staff or noted on the care plan. One of one residents reviewed for behavior. The findings included: Cross refer to F-280 as it related to the failure of the staff to implement the psychiatrist's recommendations for Resident #1 related to increased sexual behaviors. Review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was observed on initial tour of the facility on 7/7/15 at approximately 9:35 AM. Resident was noted in the dining room on Unit 1. Resident was self-propelling in a wheelchair. Resident noted to place his/her hands down his/her pants and then remove several times within a few minutes. There was no blanket across the resident's lap. Review of Resident #1's medical record revealed a Psychiatry Note dated 5/8/15. The note had a fax date of 5/12/15. The note listed the reason for consult as resident reportedly locking him/herself in the bathroom. Resident is masturbating openly in front of others. Staff unable to stop behaviors. The treatment plan and recommendation section of the note indicated will get in contact with nursing home to discuss behavioral modification for masturbating in public, which could be the best intervention. The interventions included using distraction to get the patient's attention to something else, try to avoid friendly touch especially by female staff, try to keep the patient away from other female residents and decrease contact as much as they can, try to control the content seen at the TV for something less stimulating, if patient has to sit in public try… | 2018-07-01 |
| 7118 | 7118 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2014-06-02 | 224 | D | 1 | 0 | ZIVW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, review of the facility investigation and record review, the facility failed to prevent the misappropriation of the resident's personal funds. Certified Nurse Aide (CNA) #1 allegedly misappropriate approximately $2,700.00 from Resident #1. One of one resident reviewed for misappropriation of property. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 11. The facility reported an allegation of misappropriation of Resident #1's property on 2/19/14. The description of the incident included, 2/18/2014 at 7 PM met with . POA (power of attorney) for Resident #1 and information was disclosed multiple checks made payable directly to CNA #1 from May - November 2013 totaling over $2,700. Resident denies any knowledge of why these checks would be written . The Five-Day Follow-Up Report dated 3/24/14 indicated Resident #1 handled his/her own financial affairs prior to asking CNA #1 for assistance. CNA #1 violated company policy on Financial Misconduct/ Dishonesty Policy. Review of the Nurse's Notes dated 10/5/13 at 6:45 (PM) indicated the resident stated s/he had over $1,000 stolen from him/her since at the facility. Resident #1 was also noted to have some cash money and unsigned checks scattered about in the room. Resident was encouraged to place his/her things in drawer and s/he said s/he would. A Nurse's Noted dated 1/13/14 at 11:15 AM indicated the resident was transported out of the facility to the hospital for evaluation. A green checkbook, a brown wallet with a $5.00 bill and 2 blank checks, and a checking statement were locked in a cabinet in the medication room. The nursing notes revealed no other documentation related to Resident #1's financial affairs. Review of the Social Progress Note dated… | 2017-06-01 |
| 7119 | 7119 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2014-06-02 | 226 | D | 1 | 0 | ZIVW11 | On the day of the complaint inspection, based on interviews, record review and review of the South Carolina Baptist Ministries for the Aging Financial Misconduct/ Dishonesty Prevention Policy, the facility failed to implement written policies and procedures that prohibit misappropriation of resident property. Certified Nurse Aide (CNA) #1 allegedly misappropriate approximately $2,700.00 from Resident #1. One of one resident reviewed for misappropriation of funds. The findings included: Cross refers to F-224 as it relates to the failure of the facility to prevent the misappropriation of the resident's personal funds. Certified Nurse Aide #1 allegedly used $2700.00 of Resident #1's money without his/her permission. The facility self-reported an allegation of misappropriation of resident property on 2/19/14 alleging that CNA #1 misappropriated property from Resident #1. The description of the reportable incident included .Multiple checks made payable directly to CNA #1 from May - November 2013 totaling over $2,700. Resident denies any knowledge of why these checks would be written . The Five-Day Follow-Up Report dated 3/24/14 indicated Resident #1 handled his/her own financial affairs prior to asking CNA #1 for assistance with his/her affairs. In an interview with the surveyor on 5/21/14 at approximately 11:55 AM, the facility Administrator stated that Resident #1 and CNA #1 were friends. S/he stated the Director of Nursing (DON) during the time of the incident, who is now retired, gave CNA #1 a key to the safe in her/his office so CNA #1 could get the resident's checkbook whenever s/he wanted it. The Administrator stated that s/he was not sure if the DON knew CNA #1 was writing checks. The Administrator stated that the facility did not know CNA #1 was helping Resident #1 write checks until the family called with concerns. Review of the South Carolina Baptist Ministries for the Aging Financial Misconduct/ Dishonesty Prevention Policy indicated, All employees have a responsibility to report suspected violations . Man… | 2017-06-01 |
| 7276 | 7276 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2013-05-01 | 309 | D | 0 | 1 | X3VO11 | **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 evaluate the effectiveness of pain medication for Resident # 18. ( 1 of 3 sampled residents reviewed for pain management) The findings included: The facility admitted Resident # 18 on 4/1/13 with [DIAGNOSES REDACTED]. Record review on 5/1/13 revealed the resident was receiving [MEDICATION NAME] 10-325 1 tab q6h prn (every 6 hours as needed) and routinely every morning. Review of the MAR (Medication Administration Record) for the month of April revealed the resident had received PRN (as necessary) pain medication 50 times plus the regular dose every morning. A progress note written on 4/12/13 by the physician noted the continued pain and stated see order. The Director of Nursing (DON) and RN #2 (Registered Nurse) reviewed the medical record, could not locate where an order had been written and verified the surveyors concern. The DON called the physician on 5/1/13 and the physician confirmed he/she had forgotten to write the order. An order was obtained at this time to discontinue the previous order for the routine [MEDICATION NAME]. A new order was obtained to begin a [MEDICATION NAME] every 72 hours and to change the [MEDICATION NAME] prn to 10/325 to every 4 hours as needed for break through pain. | 2017-04-01 |
| 7277 | 7277 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2013-05-01 | 333 | D | 0 | 1 | X3VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on an observation made during medication administration, interviews and review of the facility's policy entitled [MEDICATION NAME] Patches, the facility failed to ensure that the [MEDICATION NAME] Patch for Resident #29 was applied and removed as ordered by the physician. The findings included: On 4/30/13 at approximately 9:05 AM,during an observation of medication administration on Unit 2, Licensed Practical Nurse (LPN) #2 prepared medications including a [MEDICATION NAME] Patch for Resident #29. The LPN removed the previous patch from resident's right upper chest and placed a new patch. The patch removed from the resident's chest was observed to be dated 4/28/13, which indicated that the patch had been worn for 48 hours. The date on the removed patch was verified by LPN #2, who stated should have been removed on the evening of 4/28/13 at 9:00 PM. The date on the patch was also verified by Registered Nurse #1. LPN #2 also verified that the patch dated 4/28/13 was signed as removed on 4/28/13 at 9:00 PM, a new patch placed on 4/29/13 at 9:00 AM and removed on 4/29/13 at 9:00 PM. The resident was examined and no other patches were found to be on the resident. On 4/30/13 at 3:35 PM, in an interview with the facility's Consultant Pharmacist,she/he stated that the standard for facility is to apply [MEDICATION NAME] Patches in the morning and remove it at bed time. She/he stated that leaving the patch on may cause a headache or orthostatic [MEDICAL CONDITION]. Review of the facility's policy entitled [MEDICATION NAME] Patches, indicated .5. After removing the old patch .9. Apply new patch to a clean, dry site . | 2017-04-01 |
| 7278 | 7278 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2013-05-01 | 371 | E | 0 | 1 | X3VO11 | On the days of the survey, based observation, interview, and policy review, the facility failed to store fresh dining trays and soiled dining trays in a sanitary manner. The facility staff was observed to store used trays in the same cart warmer with trays that had yet to be served in 1 of 4 dining rooms. The findings included: On 4/29/2013 at 12:15 PM observation of Unit 100 dining room at the lunch meal revealed five staff members passing trays to residents in the dining room. The Staff delivered the trays to the residents and set up their meal. While setting up their meal. they removed the plate, cups, bowls, and silverware from the tray which left the plate warmer and the trash on the tray. Staff then took the tray and put it back into the cart warmer with trays that had yet to be served. On 4/30/2013 at 12:20 PM observation of the Unit 100 dining room during the lunch meal revealed serving staff putting used trays and trash back into the warming carts with trays that had yet to be served. On 4/30/2013 at 12:25 PM an interview with Licensed Practical Nurse #1 confirmed the Surveyors observations. On 5/1/2013 at 10:00 AM interview with the Dietary Manager revealed the the meal service system had changed in approximately the last three weeks from serving residents the whole tray to removing the food from the tray and placing it on the table. He/She stated that the Dietary Department did not have a policy related to serving trays in the dining room. On 5/1/13 at 10:20 AM during an interview and policy review with the Director of Nursing (DON) revealed the new Meal Service Directions were posted on 4-24-2013. The Meal Service Directions did not address any policy or procedure concerning tray handling after resident tray set up, as verified by the DON. | 2017-04-01 |
| 7279 | 7279 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2013-05-01 | 492 | E | 0 | 1 | X3VO11 | On the days of the survey, based on record review and interviews, the facility failed to ensure that Medicare claims were filed when requested and failed to stop charging residents upon request of a demand bill. Two of 3 Skilled Nursing Facility Advance Beneficiary Notices reviewed (SNFABN) were not filed as requested. (Resident #55 and #100). The findings included: An interview on 4/30/13 at approximately 3 PM was conducted with the Social Services Director to obtain a list of residents who in the last six months had additional medicare days left after being informed that their Medicare coverage had ended. Per the Social Services Director, they had no residents that had requested a demand bill. Review of the Medicare Non Coverage Notice and SNFABN form revealed Resident #55 requested a demand bill on 2/20/13 and Resident #100 also requested a demand bill on 1/28/13 that was not filed. Further review of the SNFABN form with the Social Service Director confirmed the top box was checked which indicated the request for a demand bill. An interview on 5/01/13 at approximately 8:39 AM with the Director of Finance confirmed the findings that based on the forms being checked in the top block indicating the family/responsible party requested a demand bill and the s/he was not aware that a demand bill was requested. The Executive Administrator was present during the interview and stated s/he was not aware of a demand bill request. The Director of Finance stated s/he had informed the Executive Administrator that they did not have any demand bills in the past 6 months. The Executive Administrator and the Director of Finance stated the family/responsible party may have checked the form in error and they would find out additional information, An interview on 5/01/13 at approximately 12:45 PM with the Executive Administrator revealed the Social Services Department reportedly misunderstood the form and thought checking the top box (Option 1) indicated they did not want a demand bill. The Executive Administrator stated they will … | 2017-04-01 |
| 8284 | 8284 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 280 | D | 0 | 1 | 6G5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, observation, interviews and review of the facility's Wandering/Elopement Risk Policy, the facility failed to review and revise a care plan for 1 of 1 sampled resident with exit seeking behaviors. (Resident #13's care plan was not updated related to placement and location of wanderguard bracelet). The findings included: The facility admitted Resident #13 on 9/16/08 with diagnosed that included Altered Mental Status, [MEDICAL CONDITION], Hypertension and Dementia. Record review on 2/08/12 at approximately 11:30 AM revealed a Nurse's Note dated 10/31/11 that indicated resident was found outside Unit 2 by staff. The Nurse's Note further indicated the resident was not wearing a wanderguard bracelet and the writer immediately placed one on resident's left wrist. A Nurse's Note dated 12/15/11 indicated the resident tried to leave the facility several times. There was no documentation to indicate if the wanderguard was checked or located on the left wrist. Review of the facility's Wandering/Elopement Risk Policy indicated in #2 under procedure With each quarterly, annual, or significant change assessment, the Wandering/Elopement Risk Assessment is to be completed and the care plan revised/updated to reflect the current needs of the resident. An observation on 2/08/12 at 12:30 PM revealed the resident was in his room seated in a chair. There was no wanderguard located on the resident's left wrist. The resident's care plan, incorrectly dated as last reviewed 3/20/12, indicated the resident was at risk for elopement but stated the Resident will not wear a wanderguard; he will remove all that are applied. It had not been revised to reflect the resident was currently wearing a wanderguard or where it was located. Review of the MAR (Medication Administration Records) for November 2011, December 2011, January 2012 and February 2012 did not indicate the location of the wanderguard. An interview on 2/08/12 at … | 2016-06-01 |
| 8285 | 8285 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 309 | D | 0 | 1 | 6G5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, intake and output was not recorded each shift per physician order [REDACTED]. The findings included: The facility admitted Resident # 1 on 2/08 and readmitted her on 3/18/10 with [DIAGNOSES REDACTED]. Record review on 2/7/12 revealed documentation of a recent UTI (Urinary Tract Infection) on 12/15/11 for which an antibiotic was ordered. The physician's orders [REDACTED]. The date beside the order was 12/14/10. The last documentation of I & O on the MAR (Medication Administration Record) was during October, 2011 with only initials but no actual amounts of intake or output. During an interview with the Unit Manager (Registered Nurse # 1), she reviewed the resident's record and thinned record. An order to check I & O q (every) shift was found dated 9/2/10. RN #1 continued to review the record but could not locate a discontinuation order for the I & O. She checked the MAR for February and found no documentation that I & O was being recorded. The nurse confirmed the staff were not recording intake and output on this resident per the physician's orders [REDACTED]. | 2016-06-01 |
| 8286 | 8286 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 323 | G | 0 | 1 | 6G5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that 2 of 6 sampled residents reviewed for falls remained free from accident hazards by providing adequate supervision and assistance devices to prevent accidents. For Resident #1 the facility failed to implement interventions to prevent recurrence and reduce risk after a fall. Resident #8 sustained 3 falls resulting in a shoulder dislocation and tibial fracture on separate occasions resulting from failure of the facility to provide appropriate training, supervision, and/or changes in the care plan interventions to prevent recurrence. The findings included: The facility admitted Resident #8 on 06/12/06 with [DIAGNOSES REDACTED]. Record review on 02/07/12 at 3:30 PM revealed that an incident report was written on 12/31/11 at 10:10 PM which stated, Resident was laying on floor in front of recliner chair. Staff attempted to use the lift to transfer, no connection was made. Resident slide out of recliner onto floor. The documented equipment being used at the time of the incident was lift. Nurses Notes for 12/31/11 stated that Resident #8 was complaining of right knee pain, left and right ankle pain. Resident #8 was sent to the emergency room for evaluation. Nurses Notes on 1/1/12 at 3:40 AM revealed that Resident #8 returned from the emergency room with a [DIAGNOSES REDACTED]. The second incident report, for Resident #8, which was dated for 10/21/11 at 11:15 AM stated, staff getting res (resident) off toilet on stand-up lift. Res slid out sling lowered to floor by staff. C/O (complaints of) R (right) shoulder pain, cannot move R arm and c/o R knee to ankle pain can move R leg. The documented equipment being used at the time of the incident was a stand-up lift. Nurses Notes revealed Resident #8 was sent to the emergency roiagnom on [DATE] at 12:40 PM for evaluation of right shoulder and right knee pain. Nurses Notes revealed that Resident… | 2016-06-01 |
| 8287 | 8287 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 371 | F | 0 | 1 | 6G5L11 | On the days of the survey, based on observations and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility freezer contained unlabeled/undated food. Kitchen equipment was observed soiled with dried food splatters or contained food debris, food items were not labelled nor dated, stored foods were improperly wrapped, The findings included: On 2/7/2012 at 9:20 AM, during tour of the facility's kitchen with the Dietary Manager, the Tilt Grill and the Deep Fryer contained a large amount of food debris and the oil was a dark color. A table top stand mixer had dried food splatters. The can opener attached to a counter had a black substance around the base where it was attached to the counter and in the area where the opening tip rested on the counter. The walk-in freezer had a large bag of breaded chicken strips which were taken out of the original box and had not been dated or labeled. The freezer also contained a frozen chicken which had been wrapped in aluminum foil and was partially exposed with no date. The Dietary Manager stated that the Tilt Grill and Deep Fryer were to be cleaned on the day of the tour. She removed the partially wrapped chicken from the freezer. As she removed the chicken, she stated they know they are not supposed to do that. On 2/8/2012 at 9:10 AM, during an additional tour with the Dietary Manager, the Deep Fryer was observed to contain a large amount of food debris and dark colored oil. The Tilt Grill had been cleaned. The mixer also continued to have dried splatters. The Dietary Manager stated that the Deep Fryer had been cleaned on 2/7/12 but had been used after the cleaning A cleaning schedule was requested but not provided prior to exiting the facility. | 2016-06-01 |
| 8288 | 8288 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 425 | D | 0 | 1 | 6G5L11 | On the days of the survey, based on observations, interview, and the Drug Facts and Comparisons book (updated monthly), the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 2 of 3 medication rooms. The findings included: On 2/8/12 at 10:24 AM, observation of the 300 Unit medication room revealed one 1 milliliter (ml) vial (10 tests) Tuberculin Purified Protein Derivative, Diluted/Aplisol, opened with a puncture date of 1/2/12. The Drug Facts and Comparisons book, page 2001, states (in reference to Tuberculin Purified Protein Derivative): Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency. During an interview on 2/8/12 at 10:38 AM, Licensed Practical Nurse (LPN) #1 revealed that the House Supervisor (LPN or Registered Nurse) spot checks the medication room periodically for expired medications, but there is no schedule. On 2/8/12 at 11:06 AM, observation of the 100 Unit medication room revealed one punch card of 30 tablets of Cetirizine HCl (hydrochloride) 10 mg (milligram), expired 1/31/12. During an interview on 2/8/12 at 11:33 AM, LPN #2 revealed that night shift nurses were responsible to check expiration dates on weekends and also periodically. She added that Pharmacy also comes once every couple of months and checks for expired medications. | 2016-06-01 |
| 8289 | 8289 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-08 | 514 | D | 0 | 1 | 6G5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented for Resident #4, 1 of 10 residents reviewed for allergies. Resident #4 had allergies listed on admission records and the History and Physical which were not on the Physician order [REDACTED]. The findings included: The facility admitted Resident #4 on 4/19/2011 with [DIAGNOSES REDACTED]. The resident was found to be alert and orientated and scored a 14 on his BIMS.(Brief Interview for Mental Staus). On 2/7/2012 at 2:10 PM, during review of Resident #4's medical chart, allergy documentation was reviewed. A discharge form from a hospital dated 4/2/2011 stated that the resident was allergic to Latex and [MEDICATION NAME]. A facility History and Physical (H&P) dated 4/22/2011 and signed by the attending physician indicated allergies to Latex and [MEDICATION NAME]. Another H&P from a different hospital documented the resident's allergies as [MEDICATION NAME], Latex and Shellfish. A Patient Transfer form dated 12/24/2011 also listed the resident's allergies as [MEDICATION NAME], Latex and Shellfish. An Admission/Readmission Clinical Care assessment dated [DATE] indicated the allergies were Latex, Natural Rubber, [MEDICATION NAME] and Shellfish. An assessment dated [DATE] had the allergies documented as [MEDICATION NAME] and [MEDICATION NAME] and on 4/19/11 as Latex, [MEDICATION NAME] and [MEDICATION NAME]. The POF for 12/11, 1/12/and 2/12 contained documentation of Latex and Natural Rubber as the resident's allergies. The MAR's also contained the same allergy documentation. The MAR's and POFs revealed that the resident received [MEDICATION NAME] 20 milligrams once a day. On 2/7/2012 at 4:35 PM, vinyl gloves were observed being used by the staff and in the resident's room. On 2/8/2012 at 8?20 AM, during an interview with Re… | 2016-06-01 |
| 9268 | 9268 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-27 | 225 | D | 1 | 0 | 664M11 | On the day of the complaint investigation, based on information provided by the facility and interviews, the facility failed to notify the State Agency of their final, 5 day report regarding a misappropriation investigation. One of one investigation of alleged misappropriation of funds was not reported to the State Survey and Certification Agency. The findings included: On 02/27/2012 an unannounced visit was made to the facility to investigated a facility reported allegation of misappropriation of one resident's funds. During the investigation the facility provided a summary of their investigation. Review of the investigation revealed the facility had not obtained a statement from the alleged perpetrator. The summary stated they had discussed the allegation with the perpetrator and she wanted the facility to make a payment plan. During an interview with the Executive Director, and Administrator on 3/2/12 at 9:20 AM, they confirmed they had not obtained a statement from the alleged perpetrator. They also confirmed they had not sent a five day report to the State Survey and Certification Agency. "We were not aware that we needed to send a five day report." | 2015-06-01 |
| 9269 | 9269 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2012-02-27 | 226 | D | 1 | 0 | 664M11 | On the day of the complaint investigation, based on interviews and review of the facility's written abuse policies, the facility failed to follow the policies related to reporting to the State Survey and Certification Agency. The findings included: On 02/27/2012 a review of the facility's written abuse policies and procedures revealed the following: "...Reporting: The facility shall report all alleged violation and all substantiated incidents to the state agency and to all other agencies as required by law (see attached Timeframe for Reporting): ..." Review of the DHEC Certification - Complaint Reporting Timeframe referred to under the reporting heading, page 1 of 1 stated, "...Facility investigation results sent? ...Note: Results of thorough investigation are sent within 5 working days of the incident..." Cross Refers to F-225 as it relates to the facility failure to send the 5 Day Follow-up Report to the State Survey and Certification Agency. | 2015-06-01 |
| 9518 | 9518 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 160 | D | 0 | 1 | 2LNB11 | **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 within 30 days resident funds upon death for 2 of 2 resident accounts reviewed. The findings included: Review of Resident Funds on [DATE] revealed 2 of 2 resident funds not conveyed timely upon death. During an interview on [DATE], the Accounting Coordinator confirmed that the first resident expired [DATE], and the resident's personal funds were not conveyed until [DATE]. The Accounting Coordinator also confirmed that the second resident expired [DATE], and the resident's personal funds were not conveyed until [DATE]. | 2015-04-01 |
| 9519 | 9519 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 323 | E | 0 | 1 | 2LNB11 | On the days of the survey, based on observations, interviews, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observations revealed hot water temperatures exceeded recommended limits in resident bathrooms in clustered areas on Unit 1, Unit 2, and Unit 3. The findings included: During the Initial Tour of Unit 1 on 4/04/11 at approximately 7:00 PM, the hot water in the bathroom sinks in Room 116, Room 121, Room 139, Room 120, and Room 145 felt hot to the touch. On 4/04/11 at approximately 7:15-7:30 PM, the following hot water temperatures were recorded with the surveyor's thermometer: Room 116 - 121.3 degrees Fahrenheit, Room 121 - 121.5 degrees Fahrenheit, and Room 139 - 122.5 degrees Fahrenheit. On 4/04/11 from approximatley 7:30-8:00 PM, hot water temperatures were measured with the surveyors' thermometers on Unit 2 and Unit 3 with the following measurements recorded: Room 252 - 121.4 degrees Fahrenheit, Room 253 - 121.5 degrees Fahrenheit, Room 254 - 121.3 degrees Fahrenheit, Room 258 - 121.2 degrees Fahrenheit, Room 259 - 120.7 degrees Fahrenheit, Room 333 - 121.5 degrees Fahrenheit, Room 334 - 121.7 degrees Fahrenheit, Room 337 at 122.3 degrees Fahrenheit, Room 330 - 122.2 degrees Fahrenheit, Room 331 - 122.4 degrees Fahrenheit, and Room 335 - 121.4 degrees Fahrenheit. On 4/04/11 from approximately 8:52 PM - 9:15 PM, hot water temperatures were measured with the Maintenance Director's thermometer. The following temperatures were recorded: Room 116 - 121.2 degrees Fahrenheit, Room 139 - 126.7 degrees Fahrenheit, Room 120 - 121.8 degrees Fahrenheit, Room 145 - 126.7 degrees Fahrenheit, Room 259 - 122 degrees Fahrenheit, Room 254 - 124 degrees Fahrenheit, Room 252 - 126.5 degrees Fahrenheit, Room 335 - 124.1 degrees Fahrenheit, Room 337 - 124.1 degrees Fahrenheit, Room 331 - 127.4 degrees Fahrenheit, and Room 334 - 125.2 degrees Fahrenheit. During an interview with the Administrator and Maintenance Director on 4/04/11 at approxima… | 2015-04-01 |
| 9520 | 9520 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 366 | F | 0 | 1 | 2LNB11 | During the days of the survey, based on observation and interview, the facility failed to provide a vegetable substitute of similar value to residents for 1 of 2 meals observed. The findings included: On 4/5/11 at 4:16 PM, during trayline observation of the supper meal, it was observed that no alternate vegetable was offered to the residents. The only vegetable available was a vegetable medley with broccoli, carrots, and cauliflower. The cook was observed taking carrots two at a time out of the vegetable medley to give to a resident. The cook did not portion the carrots out to provide a proper serving of carrots. On 4/5/11 at 4:20 PM, an interview with the Certified Dietary Manager (CDM) was conducted. She stated that they do not have an alternate vegetable on the steam table. She stated that the cook can pick out from the vegetable medley if a resident does not want one of the vegetables. The CDM acknowledge that the cook would be unable to provide a proper serving size and also stated that the resident would be able to taste the other vegetables even if the cook only provided the resident with one of the vegetables out of the vegetable medley. | 2015-04-01 |
| 9521 | 9521 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 368 | F | 0 | 1 | 2LNB11 | On the days of the survey, based on observation, interview, and review of the meal times effective 2/10/09, the facility failed to provide no more than 14 hours between a substantial evening meal and breakfast. The findings included: On 4/5/11 at 5:30 PM, it was observed that the supper meal was provided to residents on Unit 1. On 4/6/11 at 8:30 AM, it was observed that breakfast was provided to residents on Unit 1. Per review of the facility meal times, it revealed that Unit 3 is provided supper at 5:00 PM and breakfast at 8:00 AM. Unit 2 was provided supper at 5:15 PM and breakfast at 8:15 AM. Unit 1 was provided supper at 5:30 PM and breakfast at 8:30 AM. | 2015-04-01 |
| 9522 | 9522 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 371 | F | 0 | 1 | 2LNB11 | On the days of the survey, based on observation and interview and review of the facility policies entitled "Handwashing" and "Single-Use Gloves", the facility failed to store, prepare, distribute and serve food under sanitary conditions. The findings included: On 4/4/11 at 6:20 PM, during initial tour of the kitchen, it was observed that 2 Styrofoam boxes of employee meal and one employee drink were in the reach in refrigerator with resident food. On 4/5/11 at 11:40 AM, during observation of the lunch meal trayline, the cook was observed leaving from behind the steam table to go to the back of the kitchen to get extra bowls. The cook did not remove her gloves or sanitize her hands before returning back to the steam table to continue trayline service. On 4/5/11 at 2:15 PM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). Two ice scoopers were observed on top of the ice machine not bagged. The CDM stated that they do not bag the ice scoops. The blade of the slicer had a chip in it. It was observed that vanilla wafers in the dry storage had been opened and wrapped but not dated. A prep table was observed with 6 holes on the top of it making the surface uncleanable. In the Walk in Refrigerator in was observed that a box of sweet potatoes was on the bottom shelf with a pan of raw chicken on one side of it, a pan of raw pork on the other side, and a tray of raw pork above it. Fans in the walk in freezer and walk in refrigerator had dust around the guards and on the ceiling. On 4/5/11 at 4:16 PM, trayline for the supper meal was observed. A sanitizer bucket with solution in it was observed next to the steam table with a pan of rolls next to it. The cook was observed leaving the steam table on two occasions and going to the back of the kitchen to retrieve items without changing gloves and washing hands before returning to the steam table and continuing to plate food. On 4/5/11 at 5:15 PM, observation of trays being passed on Unit 2 was conducted. It was observed that the closed tray carts wer… | 2015-04-01 |
| 9523 | 9523 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 456 | E | 0 | 1 | 2LNB11 | On the days of the survey, based on observation and interview, the facility failed to maintain essential equipment in safe operating condition based on the ice machine being dirty and a soiled tray cart. The findings included: On 4/4/11 at 6:48 PM, during a tour of Unit 2 nourishment room, it was observed that a rust colored substance was on the inside guard of the ice machine. On 4/6/11 at 8:15 AM, during test tray observation, it was observed that an open tray cart noticeably soiled and staff still used it to place resident trays in it to pass down the hallway. On 4/6/11 at 9:00 AM, during a random observation, a rust colored substance was observed on the inside guard of the ice machine on Unit 2. On 4/6/11 at 10:22 AM, an interview with the Maintenance Director was conducted. He agreed that there was a rust colored substance on the guard of the ice machine on Unit 2 and stated that the machine needed to be cleaned. On 4/6/11 at 10:25 AM, an interview with the Housekeeping Director was conducted. She stated that her staff does not clean the inside of the ice machine. Her staff wipes down the outside of the ice machine and the inside door of the ice machine. The Housekeeping Director stated that her staff clean the tray cart after every meal but did not know why the tray cart was soiled before the breakfast meal | 2015-04-01 |
| 9524 | 9524 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 492 | D | 0 | 1 | 2LNB11 | On the days of the survey, based on review of personnel records and interview, the facility failed to obtain the state required Sled check prior to the date of hire for one Certified Nursing Assistant. (1 of 5 personnel records reviewed for Sled checks.) The findings included: Review of personnel folders on 4/5/11 revealed CNA "B" (Certified Nursing Assistant) had a Sled check done on 4/4/11. Her date of hire on the personnel folder reflected a date of 3/4/11. This was confirmed by the Administrator and Personnel Director. | 2015-04-01 |
| 9525 | 9525 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2011-04-06 | 332 | E | 0 | 1 | 2LNB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey,based on observations, record reviews and interviews, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 12.2 %. There were 5 errors out of 41 opportunities for error. The findings included: Error #1, Error #2 and Error #3: On 4/5/11 at 4:52 PM, during observation of medication pass on Unit 1, Registered Nurse (RN) #1 was observed to administer one [MEDICATION NAME] 40 mg (milligram) tablet (Error #1), two [MEDICATION NAME] 1 Gram capsules (Error #2) and two Potassium Chloride 10 mEq (milliequivalent) SA (Sustained Action) Capsules (Error #3) to Resident A, followed with water. Review of the current physician's orders [REDACTED].". The medications were administered at 4:57 PM (with water) and the resident's supper tray arrived at 5:39 PM. During an interview on 4/5/11 at 6 PM, RN #1 stated that she was aware that the medications were ordered to be given with food, but she thought the resident's supper tray would arrive by 5 PM. Error #4 and Error #5: On 4/6/11 at 9:01 AM, during observation of medication pass on Unit 1, RN #2 was observed to administer one [MEDICATION NAME] 125 mcg (microgram) tablet (Error #4) and one [MEDICATION NAME] 40 mg tablet (Error #5) to Resident B. The 2 medications were administered in applesauce and followed with water. The resident had finished her breakfast. Review of the current physician's orders [REDACTED]. During an interview on 4/6/11 at 9:23 AM, RN #2 confirmed that the [MEDICATION NAME] and [MEDICATION NAME] were ordered to be given before breakfast. | 2015-04-01 |
| 10254 | 10254 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 157 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. N… | 2014-02-01 | ||
| 10255 | 10255 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 281 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Wil… | 2014-02-01 | ||
| 10256 | 10256 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 312 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, "scratches won't leave band aid on." On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing. | 2014-02-01 | ||
| 10257 | 10257 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 280 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she "slid" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-10 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed "Resident found sitting on floor in front of chair". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed "Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse". There were no additional commen… | 2014-02-01 | ||
| 10258 | 10258 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 272 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the … | 2014-02-01 | ||
| 10259 | 10259 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 225 | E | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-2010 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room … | 2014-02-01 | ||
| 10260 | 10260 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 253 | D | GYKK11 | On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained. | 2014-02-01 | ||
| 10261 | 10261 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 323 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers… | 2014-02-01 | ||
| 590 | 590 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2020-02-07 | 583 | D | 1 | 1 | NWK011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide privacy while administering medications. Eye drops and [MED] were administered without the privacy curtain pulled and/or the door closed for one of one resident receiving eye drops and one of 2 residents receiving an injection.(Resident #4 and Resident #81) The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 1:30 PM revealed Registered Nurse(RN)#1 did not pull the privacy curtain or close the door during the administration of eye drops. During the administration of the eye drops, Resident #4's roommate and a visitor were observed in the room. The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 12:00 PM revealed during the administration of [MED], Licensed Practical Nurse(LPN)#1 did not pull the privacy curtain or close the door. During an interview with LPN #1 on 2/6/20 at 5:00 PM, s/he confirmed privacy was not provided during the administration of [MED]. During an interview with RN #1 on [DATE] at approximately 1:56 PM, s/he confirmed privacy was not provided during the administration of eye drops. No facility policy was provided addressing privacy during administration of medications. | 2020-09-01 |
| 591 | 591 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2020-02-07 | 812 | E | 1 | 1 | NWK011 | > Based on observation, interview and review of facility policy titled Food Safety, the facility staff failed to handle and store foods in accordance with professional standards in 1 of 1 kitchens and failed to provide a hands free trash can near the hand washing sink in 1 of 2 unit food service areas. The findings included: On [DATE] at approximately 10:10 AM, during initial kitchen tour, accompanied by Food and Beverage Manager the following was observed: a gallon size plastic container of tartar sauce dated [DATE], boxes of produce placed on floor of walk-in cooler, 1/2 full gallon size container of Greek salad dressing with no open date and no expiration date; gallon size container of BBQ sauce open with no date, spillage on container and on two shelves; 32 ounces chopped garlic in oil open with no date; clear plastic storage container with off white flaky substance with no label to indicate contents and no date opened. Also, in the freezer, 2 boxes of food stored on floor, 2 open bags of french fries, 1 package of hush puppies and 1 bag of pepperoni all with no label indicating date opened. The Food and Beverage Manager observed and acknowledged the improperly labeled and stored food items. On [DATE] at approximately 12:00 PM while on the Rehabilitation Unit, the hand washing sink had no hands-free trash can available to dispose of used paper towels. On [DATE]20 at approximately 12:03 PM the Certified Dietary Manager stated the trash can was inside the cabinet of the hand washing sink and confirmed the hands-free trash can was not properly placed next to the hand washing sink. On [DATE]20 at approximately 1:45 PM, review of facility policy titled Food Safety Section IV W. stated that all stored food items require a product identifier/ label and use by date. The facility policy entitled Food Safety in the Receiving and Storage Section B. stated that food must be stored in a manner to allow air circulation around food and that repackaged food will be placed in a leak-proof, pest proof, non-absorbent, sanitary … | 2020-09-01 |
| 592 | 592 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2020-02-07 | 880 | D | 1 | 1 | NWK011 | > Based on observation, interview, and review of the facility policy titled Hand washing, facility staff during the laundry process failed to wash hands after removal of gloves for one of one laundry observation. In addition, staff failed to wash hands after removal of gloves, during medication administration, for 2 of 4 observations during medication pass when gloves were worn. The findings included: During observation of the laundry process on [DATE]20 at 10:20 AM, Laundry Staff #1 was observed donning gloves to obtain soiled laundry bags and placed them in the laundry cart. After loading the cart, Laundry Staff #1 removed his/her gloves and did not wash his/her hands and continued to the next unit. During observation of medication administration on 2/6/2020 at 1:15 PM, Registered Nurse (RN) #1 was observed discontinuing an intravenous antibiotic from a Resident. RN #1 removed his/her gloves and exited the room without washing his/her hands. During observation of medication administration on 2/6/2020 at 1:30 PM, RN #1 was observed administering eye medication to a Resident, removed his/her gloves, and exited the room without washing his/her hands. During an interview with Laundry Staff #1 on [DATE]20, after the observation, s/he agreed that s/he did not wash his/her hands after removal of gloves. During an interview with RN #1 on [DATE]20 at approximately 1:30 PM, RN#1 stated s/he did not remember if hand washing had been done after the removal of gloves. S/he stated it was his/her practice to perform hand washing after removal of gloves. On [DATE]20 at approximately 3:15 PM, a review of the facility policy titled Hand washing revealed the following under Procedures: Hand washing will be performed before and after applying or administering eye drops or ointment, after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents. | 2020-09-01 |
| 593 | 593 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 157 | D | 0 | 1 | PD4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, the facility failed to ensure the responsible party and/or an interested family member was notified of the development of a pressure ulcer for Resident #180 and #203 for 2 of 3 residents reviewed with pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/11/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed Resident #180 was admitted 7 days prior to the development of a stage II pressure area to his/her sacral area. Review on 8/11/2017 at approximately 2:50 PM of the nurses notes for Resident #180 did not include documentation to ensure that the responsible party nor the spouse was notified of the development of a stage II pressure ulcer located on the sacrum of Resident #180. An interview on 8/11/2017 at approximately 3:00 PM with Licensed Practical Nurse (LPN) #2 confirmed that the responsible party/interested family member had not been notified of the development of a stage II pressure area on the sacrum of Resident #180. Review on 8/11/2017 at approximately 3:30 PM of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, states on page 3 under, Expectations, Number 1, Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including levels of urgency. The nurse shall implement appropriate interventions and have accurate information available when contacting the physician. Number 4 states, The licensed nurse shall also notify, the Unit Nurse Manager/Nursing Supervisor and the Resident and/or family. Also, Provide appropriate follow-up with staff who do not comply with facility guidelines. The facility admitted Resident #2… | 2020-09-01 |
| 594 | 594 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 272 | D | 0 | 1 | PD4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for a sacral Stage II pressure ulcer acquired after admission to the facility for Resident #180 for 1 of 3 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed he/she was admitted 7 days prior to the development of a Stage II pressure ulcer of the sacrum. Review on 8/10/2017 at approximately 4:50 PM of the MDS assessment coded on admission revealed under Section M0210 - Unhealed Pressure Ulcer(s) which asked the question, Does this resident have one or more unhealed pressure ulcer(s) at Stage I or higher? was coded with a (0) to indicate, no. Further review on 8/11/2017 at approximately 3:00 PM of the MDS assessment coded as the 14 day assessment revealed under Section M0210 coded with a (1) which indicated that Resident #180 had an unhealed pressure ulcer(s) at a Stage I or higher. Section M0300 - B. Stage 2 - number 2 was coded with a (1) and asks, Number of these Stage II pressure ulcers that were present on admission/entry or reentry, to indicate that the pressure ulcer was not acquired in the facility but the resident was admitted with the pressure ulcer of the sacrum. During an interview on 8/11/2017 at approximately 3:15 PM with the MDS/Care Plan Coordinator confirmed that the 14 day MDS assessment had been coded incorrectly and provided a corrected MDS assessment to indicate Resident #180 was not admitted with a Stage II pressure ulcer on his/her sacrum. | 2020-09-01 |
| 595 | 595 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 280 | C | 0 | 1 | PD4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to document participation of all required disciplines in the Care Plan Conferences for Residents #15, #42, #45, #46, #48, #56, #88, #180 and #203. There was no signature to verify attendance by a Dietary Representative and/or Certified Nursing Assistant (CNA) on the Plan of Care Conference Summaries for 9 of 9 sampled residents whose Care Plans were reviewed. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 12:47 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review of the Care Plan 0n 08/10/17 at 10:43 AM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 4:27 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. In an interview on 08/11/17 at 11:31 AM the Minimum Data Set (MDS) Coordinator #2, stated, if there is no signature, there is no way to verify participation. In an interview on 08/11/17 at 12:34 PM, the Director of Nursing stated the facility does not have a Care Plan policy. The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the resident's care plan dated 7/13/17 revealed Dietary and the Certified Nursing Assistant did not participate in the care plan process. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 11:02 AM of the medical record for Resident #48 revealed a form tit… | 2020-09-01 |
| 596 | 596 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 314 | E | 0 | 1 | PD4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility policy titled Categories/Staging of Pressure Ulcers and review of LLR Advisory Opinion #46, the facility failed to have a Registered Nurse stage pressure ulcer wounds for 3 of 3 pressure ulcers reviewed.(Resident #203, #48 & #180) The findings included: The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the Nursing Weekly Wound Progress Reviews revealed Licensed Practical Nurse(LPN)#2 documented the stage of the wound. Further review of the wound notes revealed there was no documentation a Registered Nurse was with LPN #2 during the staging of the wound. During an interview with the Director of Nursing(DON) on 8/11/17 at approximately 12:45 PM, he/she stated the wound nurse was Wound Care Certified(WCC) and the facility policy states if a LPN is WCC they can stage a resident's wound. He/she continued by stating wounds are discussed at risk meetings and the risk meetings are signed by Registered Nurses. The DON during the interview stated he/she made rounds with the wound nurse and sometimes performs wound care when the WCN is not available. No documentation could be provided by the DON regarding making rounds with the WCN and staging resident's wounds. Review of the facility policy titled Categories/Staging of Pressure Ulcers revealed the following: .It is the position of Five Star Senior Living that staging pressure ulcers be performed by a Registered Nurse OR a Licensed Practical/Vocational Nurse who holds a current certification as a wound care nurse, unless otherwise indicated in your state specific scope and standards of nursing practice. Review of the LLR(Labor, Licensing and Regulation) Advisory Opinion #46 states the following: It is not within the role and scope of the Licensed Practical Nurse to evaluate and/or stage vascular, diabetic/neuropathic or pressure ulcers. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review o… | 2020-09-01 |
| 597 | 597 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 329 | D | 0 | 1 | PD4911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure behavior monitoring for resident with Physician order [REDACTED].#15 identified as receiving [MEDICATION NAME] for behavior disturbances did not have any monitoring of the efficacy of the medication and/or adverse consequences. The findings include: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Record review on 8/09/2017 at approximately 3:30 PM revealed a Physician order [REDACTED].) Has hallucinations & delusions. -Order Date- 6/28/2017 1045. Record review on 8/09/2017 reveals no evidence of behavior monitoring in the Physician Orders. An interview on 08/10/2017 at 12:55 PM with LPN #1, who verified no order for monitoring behavior for medication, [MEDICATION NAME]. A review of the policy titled: Psychopharmacological Medication states 3.2 Psychopharmacological and Sedative/Hypnotic, Residents who use psychopharmacological and sedative/hypnotic medications must be reviewed on a regular basis and there must be monitoring for efficacy of the medications and Adverse Consequences. On 8/10/2017 at approximately 1:15 PM, the facility provided a copy of Physician order [REDACTED].=s/s of Dementia with behavioral disturbance, 3=Target mood/behavior: combative/resistive to care, screaming out, fidgeting behaviors, yelling, no easily redirectable every shift Document Behavior, # of Episodes, Interventions, Outcome and side effects. | 2020-09-01 |
| 598 | 598 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 371 | E | 0 | 1 | PD4911 | Based on interview, observation and record review, the facility failed to ensure: 1)Labeling and dating of refrigerated food 2)Cold foods on serving line were held at or below 41 degrees, and, 3) Safe storage of foods in refrigerator; cooked gravy was stored in refrigerator beneath raw eggs in 1 of 1 kitchen and 2 of 2 dining rooms. The findings include: During initial tour of the kitchen, on 08/08/2017 at 9:05 AM, observed 5 partially open packages of sliced cheese which had been rewrapped in clear plastic were not labeled or dated. The General Manger verified the cheese was not labeled and said the cheese should have be labeled when the package was opened and rewrapped. The Facility Policy and Procedure titled, Food Safety in Receiving and Storage, . 2.0 Procedure, The following guidelines will be followed for Receiving and Storage:, General Food Storage Guidelines, 3. Food that is repackaged will be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. On 8/10 at 4:40 PM in the Health Care Dining Room, the temperatures were taken for dinner meal service by the Dietary Employee and were as follows: Puree Ham 55.4 degrees, Sliced [NAME]toes and Lettuce 47.3 degrees. The dietary employee stated that the correct cold food temperature 35 to 40 degrees for serving line, and food must be removed from the line if not at the correct cold food temperature. The foods were removed from the line before meal service and taken back to the kitchen and put in the freezer to be chilled down, returned to the dining room at 5:15 PM, the Puree chicken salad was 39.3, Sliced [NAME]toes and Lettuce 40.1 degrees. On 8/10 at 4:55 PM in the Rehab Center Dining Room the General Manager delivered meals and took the temperatures of food prior to meal service. The Chicken Salad Sandwich was 46.5 degrees, the Potato Salad was 42.8 degrees. The General Manager said the temperatures… | 2020-09-01 |
| 599 | 599 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 372 | D | 0 | 1 | PD4911 | Based on observation, interview and record review,the facility failed to ensure the area surrounding the outside grease storage receptacle was maintained and free from spillage and leaking grease in one of one grease storage receptacle. The findings include: An observation on 08/11/2017 at 10:08 of the grease storage receptacle had spillage of black greasy substance on the concrete surface which the container was stored and the gravel in front of the grease receptacle. An interview on 8/11/2017 at approximately 10:30 AM with the General Manager of Dining and he/she said that they don't know when they are going to pick up the grease from the grease container. On 08/11/2017 at 10:48 AM, the Director of Maintenance verified the spillage of grease on gravel area and concrete surface. He/She said that the company which picks up the grease comes about every 8 weeks and, further he/she stated that there was a problem recently where they did not come timely and that is how the spillage of the black grease in the gravel area occurred. He/She said that he/she tried to clean with degreaser and this did not clean this area up. He/She provided a letter dated 8/11/2017 from Valley Proteins, Inc. which stated: .Re: Customer Number 1 (Used Waste Oil), the following is a confirmation for service for raw material services at your facility: Confirmation of Service, Service: Valley Proteins provides raw material service for the removal of waste kitchen grease. Valley Proteins furnishes these services on an 8 week frequency. We last serviced on 6/29/17. The next service expected on or around 8/14/2017. We have servicing your location since (MONTH) 1994. | 2020-09-01 |
| 600 | 600 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 441 | D | 0 | 1 | PD4911 | Based on observations, interviews and review of the facility policy titled, Laundry Handling Practices, and, Standard Precautions, the facility failed to handle soiled linen in a manner to prevent the spread of infections in 1 of 1 laundry room. The facility further failed to ensure soiled linen was bagged before leaving the resident's room and placing it in a soiled bin in the hallway on 1 of 2 halls. The findings included: An observation on 8/11/2017 at approximately 10:30 AM revealed the Laundry Worker vigorously shaking soiled linen before placing it in the soiled bins in the laundry room. Further observation on 8//11/2017 at approximately 10:35 AM revealed the Laundry Worker removing soiled linen from the soiled linen bins located in the hallway that was not bagged before placing it in the bin. During an interview on 8/11/2017 at approximately 10:45 AM the Laundry Worker stated, we shake out the linen to ensure nothing is wrapped up in it and so nothing like forks and knives are put in the washers. During the interview the Laundry Worker also confirmed that the soiled linen was not bagged prior to putting it in the soiled linen bins in the hallway. He/she went on to say that sometimes it is bagged and sometimes it is not. Review on 8/11/2017 at approximately 11:30 AM of the facility policy titled, Laundry handling Practices, under Procedure, number 3 states, Handle contaminated laundry as little as possible, with minimal agitation. Number 4 states, Bag or contain contaminated laundry bagged/contained where it is used. Do not sort or rinse in the location of use, move to identified area in laundry. Review on 8/11/2017 at approximately 11:50 AM of the facility policy titled, Standard Precautions, number 7 states, Linen: Transport linen that is soiled with blood, body fluid, secretions, or excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. | 2020-09-01 |
| 601 | 601 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 456 | E | 0 | 1 | PD4911 | Based on observations, interviews and review of the manufacturers recommendations for the facility's clothes dryers, the facility failed to ensure an excessive build up of lint was removed from inside and behind 4 of 4 clothes dryers. The findings included: An observation on 8/11/2017 at approximately 9:00 AM of the facility laundry room revealed 4 of 4 clothes dryers with an excessive build up of lint inside the clothes dryers, on the sides of the lint baskets, the upper sides of the dryers and on the wiring system. Further observation on 8/11/2017 at approximately 9:00 AM revealed a build up of lint behind the clothes dryers on the belts and ducts and on the back panels of the dryers. An interview on 8/11/2017 at approximately 9:15 AM with the Laundry Worker and the Maintenance Director confirmed the findings. Review on 8/11/2017 at approximately 9:40 AM of the Manufacturers Recommendations for the clothes dryers states under, Daily, Keep tumbler area clear and free of combustible materials, gasoline, and other flammable vapors and liquids. Number 2, reads, Remove all accumulated lint in the lint compartment area. Lightly brush any lint that may be left on the lint screen. Lint left in the lint compartment is drawn back onto the lint screen and will restrict proper air circulation. Number 5 states, Wipe any accumulated lint off of the thermostat sensing probe, cabinet hi-limit thermostat or thermistor. Failure to do so will allow a a buildup of lint in this area to act as an insulator, causing the tumbler to overheat. | 2020-09-01 |
| 602 | 602 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2017-08-11 | 463 | D | 0 | 1 | PD4911 | Based on record review, interview and observation, the facility failed to provide a functioning call bell for all residents. Two call bells were observed difficult to operate and two call bells did not function.(4 of 30 residents reviewed) The findings included: During room rounds on 8/8-9/17, the following was observed: Room 102P-call bell did not activate x 3 attempts; Room 105B-call bell did not activate after resident attempted to ring call bell; Room 207A-call bell did not activate; Room 207B-call bell did not activate. On 8/8/17 at 11:45 AM, Certified Nursing Assistant #1 and Licensed Practical Nurse(LPN)#3 confirmed the call bells for 207A and 207B would not activate. On 8/8/17 at approximately 4:00 PM, the Maintenance Director stated a wire had to be replaced and could not tell the surveyor how long the call bell had not been working or how often the call bells were checked to make sure they were in good working condition. On 8/11/17 at approximately 11:30 AM, the environmental tour was done with the Director of Nursing and call bells in Rooms 102P, 105B, 207A and 207B were checked and were functioning. During an interview with the Maintenance Director on 8/11/17, he/she stated call bells in a couple of rooms are checked randomly on a monthly basis. He/she could not tell the surveyor when the above rooms were checked last. | 2020-09-01 |
| 603 | 603 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2018-10-11 | 623 | D | 0 | 1 | BXWS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Transfer being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM, the Director of Nursing confirmed the facility did not send written notices at transfer to the resident or the resident representative. | 2020-09-01 |
| 604 | 604 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2018-10-11 | 625 | D | 0 | 1 | BXWS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Bed Hold being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM the Director of Nursing confirmed the facility did not send written notices of Bed Hold Policy to the resident or the resident representative. | 2020-09-01 |
| 605 | 605 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2018-10-11 | 812 | E | 0 | 1 | BXWS11 | Based on observation and interview, the facility failed to follow standard practices for ensuring safe food handling. The findings included: During initial tour of the facility kitchen on 10/09/18 at approximately 1:08 PM with the Executive Chef the following was observed: Reach-in cooler held open food bags and/or containers of chicken salad, potato salad, sausage links, chopped garlic and lettuce with no markings to indicate date opened. Also, there were green peppers and cucumbers with black and white mold spots. Observation in the freezers revealed fish fillets (2 bags), potato skins, and hashbrowns inside the kitchen freezer and in the freezer across the hallway bread, cooked pasta, fish, meatballs, unbaked dinner rolls, hot dogs and cookies were observed with no dating as to when opened. In the dry storage area, an open bag of pancake/waffle mix less than half full, not in a plastic bag, was observed sitting on a shelf but not dated. During the observation, the Executive Chef stated these items should have been dated at the time they were opened and prior to placing for storage as per facility policy. | 2020-09-01 |
| 5396 | 5396 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 157 | D | 0 | 1 | PCKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Responsible Party was notified of a change in condition for 2 of 15 residents reviewed for notification. The facility failed to notify the Responsible Party of changes in orders and mental status for Resident #5 and changes in orders for Resident #22. The findings included: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED].>Review of Resident #5's Nurse's Notes on 05/20/15 at 10:20 AM revealed that on 03/18/15 a new order was given for [MEDICATION NAME] 10 milligrams (mg)/day, on 04/04/15 Resident #5 refused all of her medications and said she didn't want to keep going, and on 05/12/15 a new order was given for TED hose to be worn daily. Further review of the Nurse's Notes revealed no documentation that the Responsible Party (RP) had been notified of the new orders or Resident #5's medication refusal and mood state. In an interview on 5/20/15 at 4:33 PM, Licensed Practical Nurse (LPN) #1 confirmed that there was no documentation in the Nurse's Notes indicating that the RP had been contacted regarding the new orders or Resident #5's medication refusal and mood state. LPN #1 confirmed that per facility procedures, the RP should have been notified of the new orders on 03/18/15 and 05/12/15 and the medication refusal and mood state noted on 04/04/15 and that notification should have been documented in the Nurse's Notes. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #22's physician's orders [REDACTED]. Review of Resident #22's Nurse's Notes revealed no documentation that the RP had been notified of the change in orders. In an interview on 5/20/15 at 4:33 PM, LPN #1 confirmed that there was no documentation in the Nurse's Notes indicating that the RP had been contacted regarding the new orders for Resident #22. LPN #1 confirmed that per facility procedures, the RP should have been notified of the change in orders a… | 2018-12-01 |
| 5397 | 5397 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 280 | D | 0 | 1 | PCKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews and fact sheet titled, [DIAGNOSES REDACTED], the facility failed to review and revise the Comprehensive Plan of Care for physician ordered interventions to reduce and or prevent falls for 1 of 3 residents reviewed for accidents. (Resident #94) The findings included: The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 5/21/2015 at approximately 9:52 AM of incident reports for Resident #94 revealed multiple falls. Resident #94 fell from bed onto fall mats on 2/9/2015 at 9:00 AM, with no injury. He/she fell from a wheel chair and sustained a laceration to his/her left eyebrow on 3/2/2015 and was sent to the emergency department. He/she fell with speech therapy on 4/22/15. Resident #94 fell again on 4/22/2015 and sustained a laceration to the right side of his/her head and lip. He/she was sent to the emergency room and returned later with sutures to both head and lip. He/she fell on [DATE] and sustained a small open area to left jaw and was bleeding from his/her mouth. Again on 5/17/2015 he/she fell from the bed onto the fall mat and sustained no injury. Review on 5/21/2015 at approximately 9:52 AM of a fact sheet from the National Institute of Neurological Disorders and Stroke, titled, [DIAGNOSES REDACTED] under, What is [DIAGNOSES REDACTED]?, states, [DIAGNOSES REDACTED] (PSP) is a rare brain disorder that causes serious and progressive problems with control of gait and balance, along with complex eye movement and thinking problems. This disorder begins slowly and continues to get progressively worse, and causes weakness by damaging certain parts of the brain. Under a section titled,What are the symptoms?, states, the most frequent first symptom of PSP is a loss of balance while walking. Individuals have unexplained falls or a stiffness and awkwardness in gait. Sometimes the falls are described by the person experiencing them as attacks of dizziness. Review on 5/21/2015 at approximately … | 2018-12-01 |
| 5398 | 5398 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 282 | E | 0 | 1 | PCKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the planned interventions for 1 of 3 residents reviewed for fall prevention measures. Facility staff failed to place a fall mat to the right side of the Resident #16's bed. Additionally, the facility failed to follow the care plan related to fluid restriction for 1 of 1 resident reviewed for [MEDICAL TREATMENT](Resident #209) and failed to follow positioning measures for 2 of 2 residents reviewed for positioning.(Resident #22 & #64) The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 5/20/15 of the nurse's notes revealed Resident #16 had fallen on floor on right side on 4/27/15 at 5:45 PM and 4/29/15 at 9:00 PM. Review of the resident's care plan revealed on 4/29/15 the care plan had been updated to include low bed to mat. Observations of the resident on 5/19/15 at 10:16 AM, 5/19/15 at 11:08 AM, 5/19/15 at 2:00 PM, and 5/21/15 at 5:27 PM revealed the resident was lying in a low bed without a mat beside the bed. On 5/21/15 at 5:48 PM, the Care Plan Coordinator(CPC) stated the resident should have a mat to the right side of the bed. Upon observation of the resident on 5/21/15 at approximately 5:50 PM, the CPC confirmed the mat was not by the bed as the care plan directed. The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review on 5/21/15 revealed physician's orders [REDACTED]. On 4/24/15 the physician's orders [REDACTED]. Further review of the resident's care plan revealed the resident was care planned on 4/24/15 for (1) liter fluid restriction. During record review, a recording of the resident's fluid restriction was not found. During an interview with LPN #2 on 5/21/15 at 5:13 PM, he/she stated he/she had not been measuring nor documenting the fluids the resident received. Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #64 on 5/18/15 at 5:12 PM re… | 2018-12-01 |
| 5399 | 5399 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 309 | E | 0 | 1 | PCKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Fluid Restriction, the facility failed to follow/document fluid restriction and failed to consistently monitor the catheter site for 1 of 1 resident reviewed for [MEDICAL TREATMENT].(Resident #209) Additionally, the facility failed to follow positioning interventions as ordered for 2 of 2 residents reviewed for positioning.(Resident #22 & #64) The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review on 5/21/15 revealed physician's orders for a fluid restriction on 4/22/15 for 1200 cubic centimeters(cc). On 4/24/15 the physician's orders were changed to one liter fluid restriction. Further review of the resident's care plan revealed the resident was care planned on 4/24/15 for (1) liter fluid restriction. During record review, documentation of the resident's fluid restriction was not found. Further record review revealed the resident's catheter site was located on the right chest wall. There was no documentation of monitoring of the site on 4/19, 4/20, 4/22, 4/23, 4/24, 4/25, 4/27, 4/28, 4/29/2015 and 5/7, 5/8, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/18, 5/19/2015. During an interview with Licensed Practical Nurse(LPN) #2 on 5/21/15 at 5:13 PM, he/she stated he/she had not been measuring nor documenting the fluids the resident received, he/she had just been eyeballing how much fluid was given. LPN #2 was unaware of how much fluids could be given to the resident by nursing. Per Dietary and review of the care plan, the resident received 240cc of fluids with each meal. During the interview, LPN #2 stated the catheter access site should be monitored for bleeding and infection. Review of the facility policy on 5/21/15 titled Fluid Restriction revealed under the Procedure Section #4 the following: Nursing will initiate/document I&O measurements documented on the I&O sheet every 8 hours and calculate 24-hour totals. Based … | 2018-12-01 |
| 5400 | 5400 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 323 | E | 0 | 1 | PCKJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents. Resident #16 with a history of falls to the side of the bed was observed without a floor mat. Additionally, a hydroculator in the therapy department was observed unsecured. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 5/20/15 of the nurse's notes revealed Resident #16 had fallen on floor on right side on 4/27/15 at 5:45 PM and 4/29/15 at 9:00 PM. Review of the resident's care plan revealed on 4/29/15 the care plan had been updated to include low bed to mat. Observations of the resident on 5/19/15 at 10:16 AM, 5/19/15 at 11:08 AM, 5/19/15 at 2:00 PM, and 5/21/15 at 5:27 PM revealed the resident was lying in a low bed without a mat beside the bed. During an interview with Licensed Practical Nurse #1 and #4 on 5/21/15 at approximately 5:30 PM, both stated they did not know if the resident should have a mat by the bed and could not find an order for [REDACTED]. During an interview with Certified Nursing Assistant on 5/21/15 at 6:24 PM, he/she was unsure if the resident had a floor mat but believed the resident had landing strips. On 5/21/15 at 5:48 PM, after review of the resident's care plan, the Care Plan Coordinator(CPC) stated the resident should have a mat to the right side of the bed. Upon observation of the resident on 5/21/15 at approximately 5:50 PM, the CPC confirmed the mat was not by the bed as the care plan directed. Observation on 05/18/15 from 4:20 PM until 6:34 PM revealed that a hydroculator was turned on in a gym area and the outside surface was very hot to touch. A hinged lock was on the side of the hydroculator, but it was not locked. At 6:34 PM, the facility Director of Nursing (DON) entered and locked the unit after being notified by the survey team that it was on and unlocked. There were no residents … | 2018-12-01 |
| 5401 | 5401 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 371 | F | 0 | 1 | PCKJ11 | Based on observation, record review, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The facility failed to ensure that refrigerator temperatures were in the correct range, that logs of refrigerator temperatures were maintained, that staff knew what safe food temperatures were and did not attempt to serve food that was not in a safe food temperature range, that staff were able to calibrate digital thermometers used to take food temperatures, and that foods were served in a sanitary manner. The findings included: Observation in the facility kitchen on 05/18/15 at 4:25 PM revealed that kitchen staff #1 was in the kitchen working with food and had only half of her/his hair covered with a hairnet. In an interview on 05/21/15 at 3:30 PM, the facility Certified Dietary Manager (CDM) stated that all hair should be covered with a hairnet when staff members were in the kitchen. Observation in the main dining room on 05/20/15 at 4:55 PM revealed that Dietary Aide #1 was using a digital thermometer to take food temperatures. In an interview on 05/20/15 at 4:59 PM, Dietary Aide #1 stated she did not know how to calibrate the digital thermometer. In an interview on 05/21/15 at 6:22 PM, the facility CDM stated that there was not a facility policy or procedure for calibrating digital thermometers. Observation in the main dining area on 05/20/15 at 5:10 PM revealed that the fortified pudding had a temperature of 56 degrees Fahrenheit. Observation at 5:15 PM revealed that a Certified Nursing Assistant picked up the pudding to serve to the residents. Interview with Dietary Aide #1 on 05/21/15 at 5:10 PM revealed that the pudding was prepared in house and was a cold food item. Dietary Aide #1 stated that cold food items should be below 41 degrees Fahrenheit and if they were above that temperature the items should be placed back into refrigeration until they returned to a temperature below 41 degree. Interview with the facility CDM on 05/21/15 at 5:17 PM revealed that cold foo… | 2018-12-01 |
| 5402 | 5402 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 431 | E | 0 | 1 | PCKJ11 | Based on observation, interview, and review of the facility's Audit for Expired Medications and Supplies, the facility failed to place open dates on items and failed to ensure expired supplies were not stored with other supplies for resident use in 2 of 3 medications carts and 1 of 2 medication rooms. Additionally, conflicting open dates were noted on medications. The findings included: Observation of the medication cart on the Resident Care Unit on 5/18/15 at 5:44 PM revealed the following: (1) Advair 250/50 with Lot #4ZP7193 opened 4/17/15 written on the container and 4/22/15 written on the bag containing the medication; (1) Polyethylene Glycol 3350 NF Powder for Oral Solution with Lot # 81 with no open date. During an interview at the time of the findings, Licensed Practical Nurse(LPN)#2 stated when nurses open bottles they should date the bottle and should look at the expiration date. Observation on 05-18-15 at approximately 6:00 PM of the 500 Unit Rehab to Home Med Room revealed 1 Silicone(NAME)Dover Foley Catheter, Lot # 58, 12 French (Fr), 5 cubic centimeters (cc), latex free, had expired as evidenced by use by 04-2014 noted on the package. During an interview on 05-18-15 at approximately 6:00 PM with Licensed Practical Nurse (LPN) #3, he/she, verified the Silicone(NAME)Dover Foley Catheter had expired. He/she revealed the supplies are checked weekly by the Supply Manager. During an interview on 05-19-15 at approximately 1:38 PM with the Supply Manager, he/she verified he/she had been responsible for checking the supplies in the 500 Unit Med Room weekly and had recently checked the supplies. During an interview on 05-21-15 at approximately 4:40 PM with Registered Nurse (RN) #1, he/she stated, We do not have a facility policy related to the storage of supplies but a weekly supply audit is done. Review of the facility Audit for Expired Medications and Supplies dated 04-09-15 through 05-11-15 revealed there had not been any supplies observed expired in 500 Unit Rehab to Home Med Room. An observation on 5/18/2… | 2018-12-01 |
| 5403 | 5403 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2015-05-21 | 441 | D | 0 | 1 | PCKJ11 | Based on observation, interview and review of the facility policy titled, Hand Washing, and the facility's nurse check off sheet titled, Med Pass Technique Audit Tool, the facility failed to follow a procedure for hand washing while administering medications for 1 of 4 nurses observed administering medications during the med pass observation. The findings included: During a medication pass observation on 5/20/2015 at approximately 4:30 PM Licensed Practical Nurse (LPN) #3 dropped a lancet (used for finger stick blood sugars) on the floor. He/she picked up the lancet from the floor and put it in the sharps container. He/she did not wash or sanitize his/her hands and proceeded into a resident's room to administer medications. LPN #3 was observed opening a straw and placing it in a cup of water in order for him/her to swallow medications and had not washed or sanitized his/her hands. An interview on 5/20/2015 at approximately 4:30 PM with LPN #3, confirmed he/she had not washed or sanitized his/her hands after picking up the lancet from the floor and before going into a resident's room to administer medications. Review of the facility policy titled, Hand Washing, on 5/21/2015 at approximately 4:35 PM states under section 1.0 Purpose, Proper hand washing technique must be used at all times when indicated. Hand washing is the most important component for managing the spread of infection. Section 2.0 Scope, states, All staff. Section 3.0 Fundamental Information states, Hand washing is one of the most crucial measures in reducing transmission of pathogens in healthcare settings. Review of the facility's check off sheet for Licensed Practical Nurses and for Registered Nurses on 5/21/2015 at approximately 5:00 PM titled, Med Pass Technique Audit Tool section 4.0 states, Infection control/aseptic technique correct. | 2018-12-01 |
| 6765 | 6765 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 157 | D | 0 | 1 | OM4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, review of the facility provided policy related to notification of the responsible party and interview the facility failed to notify residents legal representative and/or the physician's in a timely manner for 2 of 6 residents reviewed for notification. Resident #33 responsible party not notified of lethargic event resulting in a medication change and Resident #76 physician was not notified of recent fall. The findings included: Review of the medical record for Resident #33 on 1/23/2014 at approximately 10:30 am revealed a nurses note dated 12/2113. The nurses note read 12n (12:00 noon)- res (resident) noted to be lethargic today. Unable to stay awake to eat etc., Dr. _____ called made aware. T.O. (telephone order) D/C (discontinue) all previous [MEDICATION NAME] orders and start [MEDICATION NAME] 100 mg po (by mouth) hs(hours of sleep) only. Continued review revealed no documentation to suggest the responsible party for Resident #33 had been informed of the situation. Interview with LPN (licensed practical nurse) #1 on 1/24/2014 at 3:00 PM revealed the family/responsible party should have been notified of the situation as there had been a change in the residents condition. Review of facility policy titled Clinical Practice Information Memo number: CPIM- Resident Condition Changes that Require Physician Notification Guidelines-Expectations: #4 revealed the licensed nurse shall also notify the resident and/or family. The facility failed to follow this policy and thus failed to notify the residents family in reference to a change in the residents condition. Resident #76 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/24/2014 at approximately 1:35 PM revealed a Nurse's Note dated 1/7/2014 and written at 7:45 PM which stated, resident's wheel chair alarm sounding, and resident found on floor in hallway. Resident complained of right arm pain. Review of the incident report o… | 2017-09-01 |
| 6766 | 6766 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 274 | D | 0 | 1 | OM4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and an interview, the facility failed to formulate a significant change assessment within 14 days for 1 of 1 sampled residents newly admitted to Hospice. (Resident #77) The findings included: Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/24/2014 at approximately 10:30 AM revealed a Physicians's Order dated 8/19/2013 for Resident #77 to be admitted for Hospice Services with a new [DIAGNOSES REDACTED]. Review of Resident#77's Comprehensive Assessments revealed a Significant Change in status dated 7/6/2013 and another Significant Change in status dated 9/18/2013. The significant change completed on 7/6/2013 was 44 days prior to admission to Hospice and the significant change assessment completed on 9/18/2013 was 30 days after being admitted for Hospice care and services. An interview with the Minimum Data Set (MDS) Coordinator on 1/24/2014 at approximately 10:30 AM verified that a significant change in status assessment had not been completed within the 14 days of the change in condition for which Resident #77 was admitted to Hospice. | 2017-09-01 |
| 6767 | 6767 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 280 | D | 0 | 1 | OM4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews, the facility failed to review and revise care plans for 1 of 1 care plan reviewed for Hospice, 1 of 1 care plan reviewed for pressure ulcers and 1 of 3 care plans reviewed for range of motion. Resident #77's care plan was not updated to reflect Hospice services and a pressure sore. Resident #31's care plan was not updated to reflect the removal of a cast. Resident #52's care plan was not updated to include devices for a contracture. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 1/23/14 revealed Resident #31 sustained a [MEDICAL CONDITION] Olecranon (elbow) on 10/19/13. Review of the current care plan revealed the following interventions for the fractured left elbow: 1) Circulation assessment to affected arm; 2) Medicate for pain as ordered; 3) Check cast qs(every shift) for rough edges and tightness; 4) Check circulation of fingers to affected arm; 5) Follow-up appt(appointment) with MD Observation of the resident on 1/22/14 at 10:39 AM, 1/23/14 at 3:43 PM, and 1/24/14 at 2:54 PM revealed the resident did not have a cast on his/her left arm. When interviewed, facility staff were unable to provide a specific date when the cast was removed. No documentation was noted in the nurse's notes to reflect the date of the removal of the cast. An orthopedic note dated 12/9/13 recommended activities as tolerated; no additional treatment was indicated and to follow-up as needed. The care plan was not updated to reflect the removal of the cast and inaccurately described the resident's current care needs. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Record review on 1/21/14 revealed a therapist recommendation dated 10/8/13 for the patient to wear a left palm protector hand splint 4 hours on/4 hours off. Staff was advised to monitor for areas of pressure. Further review revealed the splint was discontinued… | 2017-09-01 |
| 6768 | 6768 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 329 | D | 0 | 1 | OM4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interviews and review of the facility policy titled Psychopharmacological Medication Use last revised 1/1/13, the facility failed to ensure that residents medication regimen was free of unnecessary medications. Resident #26 did not have an appropriate [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #26 with the [DIAGNOSES REDACTED]. Record review on 1/24/14 at approximately 11:42 AM, revealed a Physician's Telephone order which noted 1/11/14 [MEDICATION NAME] 0.5 mg (milligrams)IM (Intramuscular) now and may repeat in 2 hrs and then D/C (discontinue) and 1/14/14 [MEDICATION NAME] 25 mg po (by mouth) q hs (every night) DX (diagnoses): behaviors. During an interview with Registered Nurse #1 on 1/24/14 at approximately 1 PM, he/she confirmed the surveyor's findings and stated that the resident should have had a behavior monitoring sheet attached to the Medication Administration Record [REDACTED] During an interview with the Medical Director on 1/24/14 at approximately 3:00 PM, s/he stated due to the resident's combative behavior I ordered [MEDICATION NAME] for the resident. [MEDICATION NAME] was ineffective for the' resident due to persistent behaviors. The nurses explained to me that the resident displayed behaviors of kicking, fighting and spitting. I cannot recall if they specifically stated anything about delusions or any Psychotic episodes. We used the [MEDICATION NAME] for behaviors and the resident does not have a [DIAGNOSES REDACTED]. I did not consult with the pharmacist, s/he comes down periodically I plan on evaluating the resident for continue use of the [MEDICATION NAME]. Review of the facility policy titled Psychopharmacological Medication Use last revised 1/1/13 revealed under procedures 1.1. Where Physician/Prescriber orders a psychopharmacologic medication for a resident, facility should ensure that the Physician/Prescriber has conducted a comprehensi… | 2017-09-01 |
| 6769 | 6769 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 334 | D | 0 | 1 | OM4511 | On the days of the survey, based on record review and interview, the facility failed to provide documented evidence of education for 2 of 5 sampled resident's reviewed for education of the risks and benefits of immunizations.(Residents #31 and #52) The findings included: During record review of sampled residents #31 and #52, the education for risk and benefits related to vaccine administration was not documented as given to the resident or responsible party prior to administration or refusal of the vaccine for the year 2013. On 1/23/14 at 4:11 PM, the DON (Director of Nursing) confirmed there was no documentation on the medical record related to the family giving consent for the Influenza Vaccine for Resident #31. On 1/24/14, the ADON (Assistant Director of Nursing) stated the facility sends a letter to the families related to the Influenza Vaccine. Review of the letter stated the following:We will be giving Flu vaccines to all of our current Residents in Skilled Nursing and Assisted Living in early November. I have enclosed an authorization form for you to complete and return to The Manor by October 19th if you wish your Family Member to receive a 'Flu Vaccine. NO vaccines will be given without a completed authorization form. There was no follow-up to confirm that the families received the information mailed. | 2017-09-01 |
| 6770 | 6770 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 371 | E | 0 | 1 | OM4511 | On the days of the survey, based on observations and interview, the facility failed to store, prepare and distribute food under sanitary conditions as evidenced by food items not being discarded by the use by date; unsanitary equipment in the kitchen and in 2 of 2 dining rooms; and staff in the food preparation area without wearing a beard restraint. The observations had the potential to affect all resident's serviced by the affected areas. The findings include: During an initial tour of the kitchen on 1/21/14 at approximately 12: 23 PM, the surveyor observed 2 loaves of bread stored with the used by date of 1/18/14. Further observation of the kitchen on 1/21/14 revealed dust and grease build up on the back splash of the stove and staff with facial hair walking through the kitchen without wearing a beard restraint. On 1/23/14 at approximately 10:27 AM, during a repeated tour, the surveyor observed the can opener soiled with metal shavings and debris on the blade. During an observation of the dining rooms in the facility on 1/23/14 at approximately 11:00 AM, the surveyor observed 2 of 2 microwaves on each unit with a build up of food splatters and debris. During an interview with the Food Service Director on 1/23/14 at approximately 12:03 PM, s/he confirmed the surveyor's findings. | 2017-09-01 |
| 6771 | 6771 | MYRTLE BEACH MANOR | 425070 | 9547 HIGHWAY 17, NORTH | MYRTLE BEACH | SC | 29572 | 2014-01-24 | 428 | E | 0 | 1 | OM4511 | On the day of the survey based on record review and interview the facility failed to ensure each residents drug regimen was reviewed by a pharmacist for irregularities and appropriate dose administration for 3 of 8 residents reviewed drug regimen review. Residents medical records contained no evidence of a physician review of pharmacy reviews/recommendations for Residents #71, #33 and #25. The findings included: Review of the medical record for Resident #25 on 1/23/2014 at approximately 2:00 PM revealed pharmacy monthly reviews from August 2013 thru January 2014. Continued review revealed no documentation to indicate recommendations made by the pharmacist had been reviewed/considered by the physician. The recommendations included: 8/31/2013 MD (physician) asked to review Aspirin 325 mg (milligrams) dose while on Warfarin 9/26/2013 administration of two medications in the same pharmacology category (calcium channel blockers) 10/24/2013 higher incidence for DVT (deep vein thrombosis) while on Megace especially non-ambulatory resident. Current medication regimen includes: Warfarin with Aspirin dosed at 325 mg and Megace 400 mg twice daily, MD review aspirin dose reduction at this time? Weight and appetite review, Synthroid requires lipid TSH: if not available obtain MD order, 11/18/2013 routine administration from prn (as needed) order for Xanax 0.5 mg q8h (every eight hours) for anxiety: with at least a daily dose, may consider a longer duration benzodiazepine such as Klonopin routinely for motor restlessness? 1/08/2014 resident is taking Depakote for mood stabilization, please make sure the following are documented in the Behavior Plan of Care: all non-pharmacologic person-centered interventions tried before medications were administered, the specific target behaviors identified, and desired outcome related to the behaviors, and all care givers made aware of target behavior and expected outcomes. The record revealed no documentation to indicate the above recommendations had been addressed by the physician. Intervi… | 2017-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );