cms_SC
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date ▲ | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 737 | 737 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 550 | E | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, interviews and review of the facility's Feeding the Impaired Residents policy, the facility failed to ensure that residents were treated with dignity and respect for 3 of 3 residents triggered for dignity and 1 of 3 triggered for pressure ulcer treatment. Resident #14 not served or eating while roommate was served and eating. Residents #63 and #107 with staff standing while feeding the residents. Resident #109 with nurse observed putting dressing on resident wound then writing on the dressing after it was placed on the resident's ankle. The findings included: The facility admitted Resident #107 on 7/21/17 with [DIAGNOSES REDACTED]. During random meal observation on 2/24/20 at approximately 1:53 PM, Certified Nursing Aide (CNA)#1 was observed standing in room [ROOM NUMBER] while feeding Resident #107 who was in bed. The resident's bed was observed in a high position. A folding chair was observed in corner of room while CNA was standing while feeding the resident. The facility admitted Resident #14 on 3/18/19 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:18 AM revealed Resident #14 in room [ROOM NUMBER] with his/her roommate served and eating breaking while Resident #14 was not served or eating breakfast and the privacy curtain was not pulled. Resident #14 tube feeding was also not in progress at the time of the observation. The facility admitted Resident #63 on 9/26/18 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:23 AM revealed Certified Nursing Aide (CNA) #2 standing in room [ROOM NUMBER] while feeding Resident #63 who was in bed. Resident #63's bed was not in a high position (at level of CNA) who was standing while feeding the resident. An interview and observation on 2/25/20 at approximately 8:37 AM with Licensed Practical Nurse (LPN) #5 revealed Resident #14 roommate seated at bedside table eating his/her breakfast while Resident #14 w… | 2020-09-01 |
| 738 | 738 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 580 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify health professionals involved in a resident's care of the resident's change in nutrition/weight status. The Certified Dietary Manager (CDM) #2 failed to notify timely the doctor/nurse practitioner or dietitian of the resident's weight loss. The CMD #2 also failed to consult/notify the physician/nurse practitioner or dietitian prior to restricting some carbohydrates from the resident's diet for one of three sampled residents reviewed for nutrition. Findings: Resident #23 was admitted to the facility with diagnoses, including but not limited to, Type 1 Diabetes, Acute Kidney Failure, Dementia, Muscle Weakness, and Cognitive Communication Deficit. The physician's orders [REDACTED].#23's diet as CCD (carbohydrate-controlled diet) mechanical soft texture related to diabetes and advance dysphagia. Weekly weights, if resident gain/losses three or more pounds, reweigh, record both weights and notify MD/NP. Resident's weight record reviewed on 2/25/20 at 2:15 PM, revealed a 7.4% weight loss from December 24 through January 27 (12/24/19-113.2lbs, 1/1/20-109lbs, 1/7/20-108.1lbs, 1/14/20-104.8lbs, 1/14/20-105lbs, 1/21/20-106.2lbs, and [DATE]-104.8lb). Dietary notes reviewed on 2/25/20 at 2:15 PM revealed the following: On 12/31/19, the dietary manager (CDM) #2 adjusted Resident #23's diet per the resident's daughters' request. On 1/1/20, the resident's weight was down 3.7%, resident consuming 92% of the meal. The CDM #2 notes also said that (s/he) will recommend 90ml of sugar-free med pass twice a day. The resident's record indicated a weight loss of 4.2lbs (113.2lbs on 12/24/19 to 109lbs on 1/1/20). The resident was not reweighed, nor MD/NP notified. On 1/14/20, the resident's weight was down 2.[AGE]% (weight loss of 3.1lbs). CDM recommendation to increase med pass to 120ml twice per day. MD/NP not notified In an interview with the CDM #2 on 2/25/20 at 4:08 PM, (s/he) stated tha… | 2020-09-01 |
| 739 | 739 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 609 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to report an allegation involving abuse to the State Survey Agency within the required 2 hours after the allegation of abuse was made for 1 of 2 sampled residents reviewed for abuse. Resident #214 with an allegation of abuse being made known to the facility on [DATE] and the facility reported the allegation of abuse to the State Survey Agency on 7/29/19. The findings included: The facility admitted Resident #214 on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 2/25/20 at approximately 9:36 AM and 2:47 PM revealed a written statement from Licensed Practical Nurse (LPN) #4 signed and dated on 7/29/19 that indicated he/she was informed on 7/27/19 at 6:55 AM by LPN#3 that Resident #214 family member was very upset because Resident #214 called him/her and reported that three (3) Certified Nursing Aides (CNAs) came in the resident's room and said nothing was wrong with him/her, go to the rest room and the CNAs just pulled his/her brief off. An interview on 2/25/20 at approximately 9:43 AM with the facility Administrator revealed he/she would be the person responsible for reporting and investigating allegations of abuse at the facility. Further review of the facility's investigation revealed the Director of Nursing (DON) interviewed the resident's daughter on 7/29/19 regarding the allegation of abuse per a signed signed and dated statement on 7/29/19. According to the Initial 24-Hour Report reviewed the incident was reported the administration on 7/29/19. An interview on 2/26/20 at approximately 8:37 AM with LPN #4 who confirmed his/her written statement revealed he/she was made aware of the allegation of abuse on 7/27/19. LPN #4 further stated the nursing staff was suspended for not reporting the allegation of abuse timely. An interview on 2/26/20 at 9:02 AM with LPN #3 revealed he/she could not recall the incident. There was no documentation in LPN #… | 2020-09-01 |
| 740 | 740 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 641 | D | 1 | 1 | 848R11 | > Based on interview and record review the facility failed to accurately assess 1 of 4 residents for fall risk. Resident #[AGE]'s 12/13/19 fall risk assessment was marked incorrectly for medications, resulting in the resident being marked as NOT a high risk for falls. The findings included: Review of Resident #[AGE] fall risk assessments on 2/25/20 at approximately 1:52 PM revealed the following: 1. On 8/13/19 and [DATE], the resident scored 12 (high risk for falls). 2. On 12/13/19, conducted immediately after a fall, the resident scored a 6 (NOT high risk for falls). 3. The 12/13/19 assessment was inconsistent with previous and following assessments. The resident was marked as only being on 1-2 fall risk medications, which was not the case with other assessments. Review of Resident #[AGE] December 2019 Medication Administration Record [REDACTED]. Interview with Registered Nurse #5 on 2/25/20 at approximately 2:35 PM confirmed the 1[DATE] assessment was inaccurate. S/he clarified that, based on his/her assessment, the score should have been 18 and not a 6, indicating a much higher risk for falls. | 2020-09-01 |
| 741 | 741 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 655 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to develop a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #212, 1 of 1 sampled residents reviewed with tracheostomies. Resident #212 was admitted with a [MEDICAL CONDITION] and this information was not included in the baseline care plan. In addition, the baseline care plan was not dated to indicate completion within 48 hours. The findings included: The facility admitted Resident #212 with [DIAGNOSES REDACTED]. Review of the baseline care plan, on 02/26/20 at 09:53 AM, revealed the resident's [MEDICAL CONDITION] status was not addressed and there were no interventions related to the care of the [MEDICAL CONDITION]. A section of the baseline care plan dedicated to [MEDICAL CONDITION] status was left blank. In addition, the section of the baseline care plan indicating date of completion was left blank. During an interview with Registered Nurse (RN) #1, on 2/26/20 at 10:44 AM, RN #1 confirmed the baseline care plan did not address the resident's [MEDICAL CONDITION] status. RN #1 also confirmed the base line care plan did not have a completion date or any other documentation to indicate completion within 48 hours. RN #1 stated the nurse that does the admission is supposed to complete the base- line care plan and include all necessary information to care for the resident. RN #1 stated the admission nurse should have included the resident's [MEDICAL CONDITION] status on the baseline care plan. RN #1 also stated the admission assessment has several care areas that, when checked, will flow over to the baseline care plan. The admission assessment was reviewed with RN #1 and there was no section dedicated to [MEDICAL CONDITION] status. The admitting nurse did write a note indicating the resident had a [MEDICAL CONDITION], however, RN #1 stated the notes do not flow over to the baseline care plan. | 2020-09-01 |
| 742 | 742 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 656 | D | 1 | 1 | 848R11 | > Based on observation and interview, the facility failed to implement accident precautions from the care plan for 1 of 4 residents reviewed for accidents. Resident #[AGE] was care planned for a pad alarm to bed which was observed missing during the survey. The findings included: Review of Resident #[AGE] Care Plan on 2/26/20 at approximately 11:47 AM revealed the resident was care planned for a pad alarm to bed on 1/20/20, following a fall with major injury and subsequent hospitalization . Observation of Resident #[AGE] on 2/26/20 at approximately 12 PM revealed the pad alarm was missing from the resident's bed. Interview with Licensed Practice Nurse #2 on 2/25/20 at approximately 12 PM confirmed the pad alarm had been ordered by the physician, and that it was missing from the bed of Resident #[AGE]. The nurse immediately corrected this, and the pad alarm was observed in place for the remainder of the survey. | 2020-09-01 |
| 743 | 743 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 686 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility policy, the facility failed to provide care for 1 of 3 sampled residents reviewed with pressure ulcers. Staff failed to perform appropriate hand hygiene during wound care, in order to promote healing of Resident #63's pressure ulcer. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Resident #63's wound was observed during wound care on 2/25/20 at 3:05 PM. Licensed Practical Nurse (LPN) #1 completed the wound care with Registered Nurse (RN) #2 present. LPN #1 was observed performing hand hygiene and donning clean gloves. LPN #1 then removed the soiled dressing from Resident #63's sacrum. LPN #1 disposed of the soiled dressing in the trash and removed her/his gloves. Without performing hand hygiene, LPN #1 donned clean gloves and cleaned the residents sacral wound with wound cleanser and gauze. LPN #1 then opened a [MEDICATION NAME] dressing and placed it on the resident's sacrum. During an interview with RN #2, on 2/27/20 at 9:45 AM, RN #2 confirmed LPN #1 removed the soiled dressing, removed her/his then dirty gloves and donned clean gloves without performing hand hygiene. RN #2 confirmed LPN #1 could have potentially contaminated the clean supplies used to clean the wound. In addition, RN #2 confirmed LPN #1 potentially contaminated the sacral wound by placing the [MEDICATION NAME] dressing without completing hand hygiene. RN #2 stated that after the wound care was completed, LPN #1 stated I think I missed something. RN #2 stated s/he told LPN #1 s/he did not wash her/his hands after handling the soiled dressing and removing her/his dirty gloves. RN #2 stated she re-educated LPN #2 on appropriate hand hygiene and wound care technique. During an interview with the Director of Nursing (DON), on 2/27/20 at 9:57 AM, the DON stated she was made aware of the lack of hand hygiene after the resident's wound care was completed. The DON confirmed a lack of han… | 2020-09-01 |
| 744 | 744 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 692 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to provide adequate nutrition interventions to prevent significant weight loss in a resident at risk for altered nutrition/weight. Resident #23 had a weight decline since admission (9/10/19) and a considerable weight loss (7.4%) from December 24, 2019 (113.2lbs) to January 27, 2020 (104.8lbs) for one of three sampled residents reviewed for nutrition. Findings: Resident #23 was admitted to the facility with diagnoses, including but not limited to, Type 1 Diabetes, Acute Kidney Failure, Dementia, Muscle Weakness, and Cognitive Communication Deficit. During a lunch observation on 02/25/20 12:26 PM, the resident appeared to be enjoying (his/her) lunch. Reviewed (his/her) meal ticket, on 2/25/20 at 1:00 PM, revealed that (s/he) consumed 95% of the meal. The physician's orders [REDACTED].#23's diet as CCD (carbohydrate-controlled diet) mechanical soft texture related to diabetes and advance dysphagia. Weekly weights, if resident gain/losses three or more pounds, reweigh, record both weigh and notify MD/NP. Resident's weight record reviewed on 2/25/20 at 2:15 PM, revealed a 7.4% weight loss from December 24 through January 27 (12/24/19-113.2lbs, 1/1/20-109lbs, 1/7/20-108.1lbs, 1/14/20-104.8lbs, 1/14/20-105lbs, 1/21/20-106.2lbs, and [DATE]-104.8lb). Dietary notes reviewed on 2/25/20 at 2:15 PM revealed the following: On 12/31/19, the dietary manager (CDM) #2 adjusted Resident #23's diet per the resident's daughters' request. On 1/1/20, the resident's weight down 3.7%, resident consuming 92% of the meal. The CDM #2 notes also said that (s/he) will recommend 90ml of sugar-free med pass twice a day. The resident's record indicated a weight loss of 4.2lbs (113.2lbs on 12/24/19 to 109lbs on 1/1/20). The resident was not reweighed, nor MD/NP notified. On 1/14/20, the resident's weight went down 2.[AGE]% (weight loss of 3.1lbs). CDM #2 recommended increasing med pass to 120ml tw… | 2020-09-01 |
| 745 | 745 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 812 | F | 1 | 1 | 848R11 | > Based on observation and staff interview, the facility failed to ensure kitchen staff handled cooked food appropriately during food temping and meal serving. Also, the facility did not ensure that the kitchen dishware were dried and stored according to standard practice and that the solution to sanitize surfaces contained the appropriate amount of sanitation concentration for one of one kitchen and one of one dining-room observed. Findings: During the initial dinning observation on 2/24/20 at 12:17 PM, the meal-server touched utensils, dishware, meal tickets, and refrigerator door and cornbread with the same gloved hands. On 2/25/20 at 12:16 PM, the same meal-server did the same. S/he, wearing the same gloves, grabbed meal tickets, dishware, fruit cup, and dinner roll. Certified Dietary Manager (CDM) #2 confirmed that the server did not handle cooked food properly. The server used the same gloved hands to touch several items, including meal tickets, and grabbed the dinner rolls and place them on the residents' plate. In a follow-up visit to the kitchen on 2/26/20 at 8:55 AM, one of one red bucket observed for sanitation did not contain the recommended sanitation concentration (did not see it being used). The food and nutrition services director did the testing. There were also three wet nesting containers (wet containers stocked-up on top of each other) During food temping, on 2/26/20 at 11:45 AM, the cook touched the last cooked food item, Salisbury- steak, with the same gloved hands she used during the entire temping process. S/he touched surfaces, utensils, thermometer and wipes, and the steak with the same gloved hands. The CDM #1 confirmed that (s/he) also observed the cook touching the meat with the same gloved hands. | 2020-09-01 |
| 746 | 746 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 842 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents' medical records were accurately documented in the paper chart/electronic chart for 2 of 24 sampled residents reviewed. Resident #96 had another residents physician's orders [REDACTED]. Resident #214 had no documentation of a body audit being completed when an allegation of abuse/mistreatment was reported to the facility. The findings included: The facility admitted Resident #214 on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 2/25/20 at approximately 9:36 AM and 2:47 PM revealed a written statement from Licensed Practical Nurse (LPN) #4 signed and dated on 7/29/19 that indicated he/she was informed on 7/27/19 at 6:55 AM by LPN#3 that Resident #214 family member was very upset because Resident #214 called him/her last night and reported that three (3) Certified Nursing Aides (CNAs) came in the resident's room said nothing was wrong with him/her, go to the rest room and the CNAs just pulled his/her brief off. Further review of LPN #4 witness statement revealed the resident's skin was checked and no areas were noted to brief area. A review of the medical record (paper/electronic) on 2/25/20 at approximately 3:15 PM revealed no documentation/body audits to indicate when a skin assessment was completed related to the allegations of abuse. An interview on 2/26/20 at approximately 8:37 AM with LPN #4 who confirmed his/her written statement. LPN #4 further stated he/she did not document a skin assessment/body audit being completed the date he/she was aware of the alleged abuse. A telephone interview on 2/26/20 at approximately 9:02 AM with LPN #3 revealed he/she could not recall the alleged incident of abuse and further stated he/she would have to check his/her progress notes to determine if he/she documented anything. LPN #3 stated sometimes he/she would have documented in his/her nurses' notes. LPN #3 stated he/she did not … | 2020-09-01 |
| 747 | 747 | MANNA REHABILITATION AND HEALTHCARE CENTER | 425084 | 716 E CEDAR ROCK ST | PICKENS | SC | 29671 | 2020-02-27 | 880 | D | 1 | 1 | 848R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, facility staff failed to perform appropriate hand hygiene to provide a safe and sanitary environment for the residents. After completing wound care for Resident #63 (1 of 3 sampled residents reviewed for pressure ulcers), a staff member potentially contaminated multiple items in the room prior to completing hand hygiene. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Resident #63's wound was observed during wound care on 2/25/20 at 3:05 PM. Licensed Practical Nurse (LPN) #1 completed the wound care with Registered Nurse (RN) #2 present. After completing the wound care, LPN #1 removed her/his gloves. LPN #1 touched a bottle of wound cleanser, then turned towards the sink. Before LPN #1 could wash her/his hands, RN#2 asked LPN #1 to get a clean brief so RN #2 could change the resident's brief. LPN #1 opened the resident's closet door, reached inside and removed a clean brief from the closet. LPN #1 then closed the closet door and handed the brief to RN #2. LPN #1 then washed her/his hands. During an interview with RN #2, on 02/27/20 at 10:55 AM, RN #2 confirmed LPN #2 did not perform hand hygiene after wound care prior to touching the above mentioned items. RN #2 stated those items had the potential to be contaminated based on the lack of hand hygiene. | 2020-09-01 |
| 1357 | 1357 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2020-02-26 | 880 | D | 0 | 1 | N8K811 | Based on observations, interviews and facility policy review, the facility failed to ensure proper handwashing techniques were followed for one of six nurses observed during medication pass and one of one nurse observed during wound care. The findings include: A review of the facility's policy and procedure for Handwashing/Hand Hygiene, revised August 2015, indicated Washing hands vigorously lather hands with soap and water; Rinse hands thoroughly under running water; Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel; Discard towels into trash. During an observation and interview on 02/25/20 at 3:32 PM, Registered Nurse (RN) #1 was observed passing medications to Resident #46. RN #1 began by washing her/his hands. S/he washed her hands with soap and water, rinsed her hands, then used clean hands to dispense a paper towel using the paper towel lever. Touching the paper towel lever posed a risk of contaminating clean hands after handwashing. S/he then dried hands with the paper towel and used a paper towel to turn off the water. RN #1 then administered the resident's medication. S/he returned to the resident's bathroom to wash hands. After washing her hands with soap and water, s/he again used clean hands to dispense a paper towel, using the paper towel lever. When questioned about the observation and her/his in-servicing on handwashing, s/he indicated s/he hadn't been educated on pre-dispensing a paper towel or using another means of dispensing a paper towel to prevent contaminating her clean hands. During wound care observation and interview on 02/25/20 at 1:31 PM, RN #2 was observed performing wound care for Resident #101. S/he began by washing hands in the resident's bathroom. S/he washed her hands with soap and water, rinsed hands, then used clean hands to dispense a paper towel using the paper towel lever. S/he dried hands with the paper towel and used a paper towel to turn off the water. S/he cleaned the resident's bedside table and washed her/his hands again afte… | 2020-09-01 |
| 4128 | 4128 | THE LODGE AT WELLMORE- TEGA CAY | 425407 | 111 WELLMORE DRIVE | FORT MILL | SC | 29708 | 2020-02-20 | 550 | D | 0 | 1 | D2YG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that staff knocked on residents doors to seek permission prior to entering the residents' rooms. Staff was observed entering multiple residents rooms without knocking on 1 of 2 units. The findings included: On 2/18/20 at approximately 10:43 AM, Certified Nursing Aide (CNA) #1 was observed entering room [ROOM NUMBER] without knocking. The CNA began moving items around in the resident's room. CNA #1 confirmed the observation and stated he/she usually knocks when the door was closed. CNA #1 further stated he./she observed the resident was sleeping and he/she did not want to intrude. An observation on 2/18/20 at approximately 12:35 PM revealed a Cook/Server at the facility walked into room [ROOM NUMBER] without knocking (both residents were the room). During an interview the Cook/Server acknowledged he/she entered the resident's room without knocking. An observation on 2/19/20 at approximately 7:30 AM revealed a CNA #2 entering rooms [ROOM NUMBERS] without knocking. The CNA #2 was not observed asking the residents' permission to enter the room. An interview on 2/20/20 at approximately 8:50 AM with the Administrator and DON revealed staff was trained related to knocking on residents rooms and asking permission to enter during orientation. | 2020-09-01 |
| 2439 | 2439 | MEDFORD NURSING CENTER | 425176 | 105 MEDFORD DRIVE | DARLINGTON | SC | 29532 | 2020-02-19 | 576 | C | 1 | 1 | 7SU311 | > Based on interviews and record reviews, it was determined the facility failed to deliver mail to residents on Saturdays. The Resident Census and Conditions of Residents form, dated 0[DATE], identified [AGE] residents who resided in the facility. The findings included: On 02/18/20 at 1:17 PM, a confidential resident group meeting was attended by eight cognitively alert residents. They were asked if mail was delivered to residents on Saturdays. None of the residents in attendance thought mail delivery was available on Saturdays. On 02/18/20 at 2:03 PM, the Business Office Manager was asked if mail was delivered to residents on Saturdays. She said, No. She stated the mail stayed locked in the mailbox until Monday, and then she would give the mail to the Activities Department staff to deliver to the residents. On 02/18/20 at 3:06 PM, the Administrator stated in October 2019 the delivery of residents' mail on Saturdays was identified as an area which needed improvement. He stated, at that time, charge nurses were provided a key to the mail, so, if a resident was expecting mail on the weekend, the charge nurse could check for it. On 02/18/20 at 3:37 PM, the Activities Director was asked if mail was delivered to residents on Saturdays. She stated, if a resident was expecting mail on Saturday, they could ask the nurse to check the mail. She stated the nurses had the key to the mail. On 02/18/20 at 3:41 PM, the Director of Nursing (DON) was asked if mail was delivered to residents on Saturdays. She stated the charge nurses had a key to access the mail. She stated the key to the mail was provided, so if a resident was expecting mail on the weekend, the charge nurse could check for it. She was asked if residents were aware charge nurses had access to the mail on Saturdays. She reviewed the resident council meetings minutes since October 2019, as well as information provided to residents in the admission packet and concluded residents had not been informed mail was available to them on Saturdays. She stated the charge nurs… | 2020-09-01 |
| 2440 | 2440 | MEDFORD NURSING CENTER | 425176 | 105 MEDFORD DRIVE | DARLINGTON | SC | 29532 | 2020-02-19 | 812 | F | 1 | 1 | 7SU311 | > Based on observations, interviews and record review, the facility failed to ensure food preparation utensils and equipment were cleaned, sanitized and stored dry. This had the potential to affect all the residents at the facility. The census was [AGE]. The finding included: 1. During the initial tour of the kitchen on 0[DATE] at 9:10 AM, two long handled strainers, one round approximately four inches in diameter and one square approximately 4 inches across, were hanging over a food preparation table. The strainers were observed to have silver colored handles and around the strainer portion, there was a brownish colored buildup. During an additional kitchen tour, on 0[DATE] at 9:53 AM, the square shaped strainer was in use. It was being used to strain green beans. Upon a closer examination with the Certified Dietary Manager (CDM) and Nursing Home Administrator (NHA), it was determined that the brownish matter around the base of the handle, the frame of the strainer and within the mesh of the strainer, was a build up of food matter. The CDM was able to scrape off the matter with his/her fingernail. On 0[DATE] at 10:03 AM, the CDM was interviewed. S/He stated the strainer was made of stainless steel and should not rust. He determined the brownish matter was a build up of food debris and the strainer should not have been in use. On 0[DATE] at 10:05 AM, the round strainer was observed to be in the dirty dish area. The CDM stated the round strainer had the same food debris build up and should not have been in use. On 0[DATE] at 10:07 AM, located on the clean area of the drying rack were seven cooling racks used for fried food. All seven racks were observed to have a build up of food debris on the underside of the racks. The CDM removed the racks from the clean area and placed them in the soiled area. The CDM stated that before they were used again, the racks would have to be scrubbed by hand. 2. On 0[DATE] at 10:10 AM, located on the clean area of the drying rack were six metal 4 food pans and four metal 6 food pans.… | 2020-09-01 |
| 1007 | 1007 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2020-02-13 | 577 | C | 0 | 1 | QHZF11 | Based on observations and interviews, the facility failed to ensure the results of the most recent survey conducted by the Federal and State surveyors were readily accessible and available to facility residents and visitors. The most recent state agency survey results were not accessible and there was no posting to indicate where the most recent survey results were located on 2 of 2 units observed. The findings included: Upon entering the facility on 2/10/2020 at approximately 10 AM revealed no state agency survey results available in the front lobby of the facility and no posting as to the location of the most recent survey results. During the state agency group interview on 2/10/2020 at approximately 4 PM, 8 of 9 residents in group stated they did not know where the most recent state agency survey results were located. An interview and observation on 2/12/2020 at approximately 2:34 PM with the facility's Receptionist/Human Resource Staff revealed that the most recent state survey book was behind the receptionist desk on desk on the 1st floor. The Receptionist/Human Resource Staff acknowledge the state agency survey information was not accessible by the receptionist desk and further stated there was no posting to inform the residents or visitors as to where the most recent state agency survey book could be located. An observation on 2/12/2020 at approximately 2:43 PM with the facility's pharmacist revealed the state agency survey book was behind the nurses' station on a shelf. The survey results were not current or accessible. An interview and observation on 2/12/2020 at approximately 2:45 PM with LPN#1 confirmed the state agency survey results were not readily accessible, the survey results were not current and there was no posting to inform the residents or visitors as to the location of the survey results on the 2nd floor. | 2020-09-01 |
| 1008 | 1008 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2020-02-13 | 578 | D | 0 | 1 | QHZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility's Advance Directive Documentation policy, the facility failed to ensure the residents with Advance Directive for Do Not Resuscitate (DNR) were given the opportunity to sign their own advance directive. Resident #95 and #[AGE] advance directive was signed by a family member without any physician's documentation with signatures to determine the resident's lack of decisional capacity to sign his/her own advance directive. 2 of 24 sampled residents reviewed. The findings included: Resident #95 was admitted to facility on [DATE]20 with [DIAGNOSES REDACTED]. A review of the medical record on 2/10/2020 at approximately 2:17 PM revealed Resident #95 had an advance directive for Do Not Resuscitate that was signed by a family member. Further review of the medical record revealed there were no two physician's signature to indicate the resident did not have decisional capacity to make health care decisions for his/herself. The facility admitted Resident #[AGE] on 10/17/2019 with [DIAGNOSES REDACTED]. A review of the medical record on 2/10/2020 at approximately 3:12 PM revealed Resident #[AGE] was on hospice and that his/her advance DNR was signed by a family member with no physician's signature to determine the resident lack the decisional capacity to formulate his/her own advance directive. An interview on 2/10/2020 at approximately 2:45 PM with the Director of Nursing (DON). The DON stated the resident Resident #95 and #[AGE] signed their own advance directive and subsequently provided documentation showing that a family member signed the advance directive for Resident #95 and #[AGE]. An interview on 2/11/2020 at approximately 8:05 AM with the Administrator who confirmed there were no two physician's signatures to indicate Resident #95 did not have the decisional capacity to sign his/her own advance directive. The Administrator further stated he/she will check the physician statement for Re… | 2020-09-01 |
| 1998 | 1998 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2020-02-13 | 697 | D | 0 | 1 | UJ6C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure Resident #12 was as pain free as possible during pressure ulcer treatment for one of 2 pressure ulcer treatments observed. During pressure ulcer treatment, Resident #12 indicated the pressure ulcer treatment was painful. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Record review on 2/11/20 at 3:57 PM revealed Resident #12 had an inherited, unstageable pressure ulcer to the left heel. Review of physician orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the physician's progress note dated 2/3/20 revealed Resident #12's left heel wound had eschar with drainage and debridement was recommended. Review of the Medication Administration Record(MAR) revealed Resident #12 received [MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg on [DATE] at 4:51 AM. Further review of the MAR indicated [REDACTED]. Observation of pressure sore treatment on [DATE] at 1:25 PM revealed during the removal of the dressing, cleaning of the wound, drying the wound, and placement of the new dressing, Resident #12 moaned or stated it hurt. During the care of the wound, using gentle technique, Registered Nurse(RN) #1 did not ask the resident if s/he would like the treatment stopped. During the treatment, RN #2 encouraged Resident #12. During an interview with RN #1 on [DATE] at 2:00 PM, s/he stated s/he knew the resident well and the behaviors exhibited were not new. RN #1 further stated during the visit to the wound clinic Resident #12 exhibited the behaviors even when the area was anesthetized. S/he continued when care was given, Resident #12 did not draw back his/her leg. RN#1 stated that s/he knew the surveyor wanted to see the wound care and s/he was focused on the wound care. On [DATE] at 2:13 PM, RN #1 added, the resident never asked me to stop the treatment. During an interview with the Director of Nursing on [DATE] at 2:05 PM, s/h… | 2020-09-01 |
| 1999 | 1999 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2020-02-13 | 880 | D | 0 | 1 | UJ6C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policies titled Handwashing/Hand Hygiene and Departmental(Environmental Services)-Laundry and Linen, the facility failed to ensure infection control procedures were followed during the laundry process. Laundry staff was observed to enter multiple rooms without changing gloves, touching multiple items with soiled gloves, and enter into the nutritional room wearing the gown used during sorting for one of one laundry observation. The findings included: Observation of the laundry on 2/12/20 at 10:00 AM revealed Laundry Staff #1, after donning gown and gloves, entered into room [ROOM NUMBER] and placed loose clothing items into a bag. After exiting the room, s/he reached into his/her pocket, removed a pen, placed a piece of paper on the wall, wrote identifying information, and placed the paper with the bag of soiled items. Laundry Staff #1 entered into room [ROOM NUMBER] and repeated the process. In addition, prior to exiting the room, Laundry Staff #1 turned the lights off. Laundry Staff #1 opened the laundry door, loaded washer #1, sprayed Shout on the clothes, added detergent, closed the machine door, and started the washer. The same procedure was used for washer #2. After finishing the procedure for washer #2, Laundry Staff #1 removed the soiled gloves. Laundry Staff #1 exited the laundry room wearing the soiled gown, entered into the nutritional room on the unit and washed his/her hands. After washing his/her hands, Laundry Staff #1 re-entered the laundry room and did not remove the soiled gown until this surveyor questioned at what point would the gown be removed. After sharing the above concerns with Laundry Staff #1, s/he stated understanding of the concerns. Review of the facility policy titled Handwashing/Hand Hygiene revealed under the Policy Interpretation and Implementation the following: 8. Hand hygiene is the final step after removing and disposing of personal protective equipm… | 2020-09-01 |
| 1298 | 1298 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2020-02-12 | 730 | E | 1 | 1 | WQQ411 | > Based on interview and record review, the facility failed to ensure competency in their Certified Nursing Assistants (CNAs) by not completing the required annual performance evaluation on staff with a hire date of more than one year prior to the survey. This failed practice affected 43 CNAs out of 65 CNAs employed by the facility. The findings include: An interview was done with Registered Nurse (RN) #1 on 02/12/20 at 1:46 PM concerning staffing and staff competency. RN #1 was asked about the annual performance evaluations for their CNAs. This evaluation is to be used to determine the 12 hours of in-services required by Centers for Medicare and Medicaid Services (C[CONDITION]) per year. RN #1 stated that the Interim Director of Nursing (IDON) took care of that. An interview was completed with the IDON on 02/12/20 at 2:20 PM. She stated that these evaluations were not being done at this time. She stated that she was aware of this problem but had not had a chance to address it yet. The IDON was unable to provide any annual performance evaluations for the CNAs. | 2020-09-01 |
| 1299 | 1299 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2020-02-12 | 758 | E | 1 | 1 | WQQ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, it was determined the facility failed to provide a diagnosis, which would justify the use of [MEDICATION NAME] (an antipsychotic medication), for one (Resident #14) of five sampled residents whose clinical records were reviewed for unnecessary medications. The findings included; The Physician's Desk Reference included an Antipsychotic Black Box Warning, which included: Elderly patients with dementia-related [MEDICAL CONDITION] who are treated with antipsychotic drugs are at an increased risk of death. Resident #14 had a [DIAGNOSES REDACTED]. The clinical record contained no documentation of a [DIAGNOSES REDACTED]. The resident ' s quarterly assessment, dated 11/05/19, documented the resident was able to make herself understood, understood others, and she was moderately impaired in cognition. The assessment also documented the resident had no hallucinations, delusions, or potential indicators of [MEDICAL CONDITION]. A nurse's note, dated 1[DATE]19 at 5:05 PM, documented the resident was confused and crying uncontrollably. The note also documented the physician was notified and a new order was issued for [MEDICATION NAME] to be administered. A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 7:01 PM, documented that the resident was yelling for help and was found lying on the floor with her head up against the wall. The resident was noted to be confused about time and place. She was assessed by staff and was noted to have a bump on the back of the head. On 02/12/20 at 10:02 AM, the resident was observed sitting in a recliner in her room. She was asked if she ever felt anxious? She stated she did; usually when she wanted to go home. She was asked if there was anything that would make her feel better. She stated she would just tell herself to settle down and soon she would feel better. At 1:41 PM on 02/12/20, the Director of Nursing (DON) was asked if the resident had a [DIAGNOSE… | 2020-09-01 |
| 1300 | 1300 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2020-02-12 | 759 | E | 1 | 1 | WQQ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record reviews, the facility failed to ensure its medication error rate was not greater than 5 percent for two of three residents observed (Resident #126 and Resident #20). The facility's medication error rate was 11.43%. There were four errors out of 35 opportunities for errors. 1. During medication pass observation on 02/12/20 at 8:38 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications to Resident #126. She administered [MEDICATION NAME] ([MEDICATION NAME]) 1[AGE] milligrams (mg) one tablet by mouth. She poured the medication from the facility's stock on the medication cart. A review of Resident #126's current physician's orders [REDACTED]. During an interview on 02/12/20 at 8:55 AM, LPN #1 was questioned about the physician's orders [REDACTED]. She looked in the medication cart and stated she didn't even have [MEDICATION NAME] [AGE]mg tablets on the cart. She indicated she did not catch the error. 2.a. During medication pass observation on 02/12/20 at 9:50 AM, Licensed Practical Nurse (LPN) #2 was observed administering medications to Resident #20. She administered potassium 10 milliequivalents (meq) four capsules by mouth. A review of Resident #20's current physician's orders [REDACTED]. During an interview on 02/12/20 at 10:14 AM, LPN #2 was questioned about the order for potassium 40meq to be administered at 8:00 AM. She stated medications are supposed to be administered within one hour before or one hour after the ordered administration time. When questioned why the medication was administered late, she indicated she was running late with the medication pass because she had the whole nursing hall by herself. She further stated that she normally had the whole nursing hall by herself. During an interview on 02/12/20 at 11:10 AM, the Interim Director of Nursing (DON) was questioned about timing of the potassium administration, and she stated, it was late. She indicated the n… | 2020-09-01 |
| 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 |
| 3663 | 3663 | OPUS POST ACUTE REHABILITATION | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2020-02-07 | 761 | E | 0 | 1 | 1NS311 | Based on observations, interviews and facility policy the facility failed to assure that medications were securely stored in 1 of 2 medication rooms. The findings include: On 2/4/20 at approximately 9:48 AM the Station One Medication Room was observed open with an unaccompanied [ENTITY] representative inside the room. On 2/4/20 at approximately 9:50 AM s/he stated that a nurse let him into the medication room to exchange oxygen tanks which are stored there. On 2/4/2020 at approximately 9:57 AM, when asked about access to the medication room, RN (Registered Nurse) # 1 stated Isn't the oxygen guy in there? indicating RN#1 was aware the Oxygen Supply representative was in the Medication Room unaccompanied. On 2/4/20 at approximately 10:11 AM the Station One Medication Room was inspected and revealed unlocked cabinets which contained over-the-counter floor stock medications and 10 milliliter syringes of [MED] Chloride 0.9 % (percent) for Injection. On [DATE] at approximately 10:37 AM the Administrator provided a copy the Medication Storage in the Healthcare Centers policy revised 9/15/17. A review of the policy revealed under Policy Statement The medication supply is accessible only to licensed nursing personnel and pharmacy personnel, under Scope This policy applies to all licensed nursing staff of a [ENTITY] and under Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications. On 2/4/20 at approximately 10:59 AM RN # 1 stated that one of the nurses must have let the oxygen supplier in the med room and didn't stay with him. On 2/4/20 at approximately 1:06 PM the Director of Nursing stated there should have been a licensed staff member with her/him in the Medication Room. | 2020-09-01 |
| 3664 | 3664 | OPUS POST ACUTE REHABILITATION | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2020-02-07 | 812 | F | 0 | 1 | 1NS311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to discard expired foods from a reach-in cooler and the emergency food supply for one of one kitchens observed. Findings: During the initial kitchen observation on [DATE] at 9:19 AM, the surveyor and certified dietary manager (CDM) noticed an unopened 5 pound box of potatoe salad with a used by day of [DATE]. On [DATE] at 4:00 PM, during emergency food supply observation and review, six #10 cans of Pear slices and seven # 2.5 cans of cream of celery expired on ,[DATE]. The CDM was present during the observation and review. S/he confirmed that these items expired on ,[DATE]. | 2020-09-01 |
| 321 | 321 | GREENVILLE POST ACUTE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2020-02-06 | 725 | D | 1 | 1 | NI3N11 | > Based on staff and resident interview the facility failed to provide sufficient nursing staff to care for resident's needs for 2 out of eight Residents investigated. Residents #272 and #53 expressed concerns regarding sufficiency of staff. The findings included: Interview with Resident #272 on 2/4/20 at 12:18 PM The Resident stated it takes 20 to 60 minutes for staff to respond to a call light/request for assistance. The resident also mentioned that s/he sat in waste for over an hour after requresting staff assistance. Interview with Resident #53 on 2/4/20 at 2:58 PM, The Resident stated there is a shortage of weekend staff especially second shift. The Resident stated that s/he asked and had to wait over an hour for staff to put him/her to bed. An interview on 2/6/20 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated that once or twice a week she does not have time to complete all assignmenst and did not put Resident #53 to bed prior to shift change as she was assigned. CNA #1 also stated once or twice a week she doesn't have time to complete rehabilitation therapy on Resiendents as ordered due to short staffing. | 2020-09-01 |
| 322 | 322 | GREENVILLE POST ACUTE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2020-02-06 | 732 | D | 1 | 1 | NI3N11 | > Based on interview and observation, the facility failed to post cumulative staffing hours worked at the beginning of each shift. The findings included: Observation of all bulletin boards for staff postings on 2/4/20 at 10:40 AM revealed cumulative hours were not listed. Observation of all bulletin boards for staff postings on 2/5/20 at 1:48 PM revealed cumulative hours were not listed. Observation of all bullentin boards staff postings on 2/6/20 at 1:10 PM revealed cumulative hours were not listed. A Record review of (MONTH) 2019, (MONTH) 2019, and (MONTH) 2020 on 2/6/20 at 1:15 PM revealed cumulative hours had been listed with these postings. Durring an interview with the Staffing Coordinator on 2/6/20 at 1:20 PM, The Staffing Coordinator stated s/he does not post cumulative hours until the end of the shift, rather than the beginning of each shift as required. S/he confirmed that visitors will not see the postings until end of shift. | 2020-09-01 |
| 2785 | 2785 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2020-01-30 | 693 | D | 0 | 1 | 3FD811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, it was determined that the facility failed to ensure the administration of an enteral feeding was consistent with and followed the physician's orders. This failed practice affected one (Resident #53) out of 30 sampled residents. The facility failed to ensure Resident#53 received the total amount of enteral feeding as ordered by the Physician and recommended by the Dietitian. The resident was receiving the enteral feeding for approximately 21 hours instead of 22 hours. Findings: Review of the facility policy, Enteral and [MEDICATION NAME] Feedings, revised 1/18/17, documented under Procedures, General Guidelines: Orders to include: Rate/Frequency/duration of feedings. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed Resident#53 as having problems with short- and long-term memory problems and severely impaired cognition. The MDS also documented the resident as receiving more than 51% of total calories through a gastrostomy tube. Review of Resident#53's physician's orders, dated 12/9/19, documented an enteral order for Glucerna 1.5 @(at) 40 cc (cubic centimeters) per hour for 24 hours. On 12/19/19 the order was changed to Glucerna 1.5 @45 cc per hour for 22 hours. On 1/4/2020, the order was changed to Glucerna 1.5 @ 55cc per hour for 22 hours. Review of Resident#53's care plan, dated 12/31/19, documented, (Resident#53) is a new admission requiring a therapeutic feeding of Glucerna 1.5 remains NPO (nothing by mouth) at this time. Listed under goals was documented, Will continue to tolerate tube feedings and flushes and will not experience any significant weight changes. Listed under approaches, Peg tube feeding and flushes per MD order. Review of Resident#53's Nutritional Progress notes, dated 12/19/19, documented the resident's weight was 145 and recommended Glucerna 1.5 @45 cc per hour for 22 hours t… | 2020-09-01 |
| 3407 | 3407 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2020-01-30 | 550 | E | 1 | 1 | GPPM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined the facility failed to treat 3 of 3 sampled residents with dignity during a noon meal service (Residents #50, #[AGE], and #[AGE]). The administrator identified ten additional residents who required assistance with eating on ward 130. One sampled resident (Resident #50) had a food tray placed beside him and was not assisted with eating for 25 minutes. Two Certified Nurse Aides (CNAs) #1 and #2 were observed standing beside two sampled residents (Residents #[AGE] and #[AGE]) while assisting the residents to eat. The findings included: 1. A quarterly Minimum Data Set assessment (MDS), dated [DATE], documented Resident #50 was totally dependent on staff for all activities for daily living (ADLs). He was impaired in range of motion with upper and lower extremities, and he was cognitively impaired in decision making. On 0[DATE] at 11:25 AM, resident #50 was observed sitting in the dining room. A food tray was placed on the table next to the resident. CNAs #1 and #2 were observed to be feeding two (Residents #[AGE] and #[AGE]) sampled residents. At 11:49 AM, CNA #2 started to assist Resident #50 with eating. CNA #2 was asked why the resident had not been fed when his food tray was placed beside him. She stated because they were already feeding other residents. She was asked if it would have been possible to have fed two residents at the same time. She didn't respond. On 01/29/20 at 12:00 PM, the Director of Nurses (DON) was asked what an acceptable amount of time was for a food tray to sit beside a resident before staff assisted the resident to eat. The DON stated 45 minutes was an acceptable amount of time for a resident to sit with his food beside him. She was asked if it was a dignity issue for the resident to wait until everyone had eaten before he was fed. She added that it wouldn't bother her. She stated if there wasn't enough staff someone would have to wait to eat. The DO… | 2020-09-01 |
| 3408 | 3408 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2020-01-30 | 641 | D | 1 | 1 | GPPM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Behaviors for one of 28 sampled residents (Resident #[AGE]). The findings included: Resident #[AGE] had [DIAGNOSES REDACTED]. Record review of nurse's notes, dated for 11/28/19, revealed on that day Resident #[AGE] was verbally abusive and using profanity. Record review of nurse's notes dated for 12/04/19, revealed on that day Resident #[AGE] again had increased aggression, was verbally abusive and swearing at staff. Record review of the annual MDS, dated [DATE], revealed Resident #[AGE] was moderately cognitively impaired. The MDS also revealed Resident #[AGE] had no behavioral issues during the 7-day assessment period between 11/28/19 through 12/04/19. During an interview on 01/30/20 at 4:28 PM, the Social Worker (SW) specified she completed Sections D, E, F and Q on the comprehensive MDS. The SW reviewed the nurse's notes and stated, That was my error. The SW indicated Resident #[AGE]'s behavior should have been documented on the annual MDS. During an interview on 01/30/20 at 11:18 AM, the Administrator stated it was his expectation that staff code the resident's status accurately on the assessment. | 2020-09-01 |
| 3409 | 3409 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2020-01-30 | 656 | D | 1 | 1 | GPPM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and record review, the facility failed to develop a care plan for the use of a waist belt for one of 28 residents (Resident #9). The findings included: Resident #9 was admitted with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was severely impaired. She required total assistance with bed mobility and transfers. The MDS did not indicate any use of restraints. During an observation on 0[DATE] at 2:43 PM, Resident #9 was observed sitting up in a wheelchair. She had a blue soft Velcro belt around her waist. She was not able to be interviewed. A review of the resident's care plans did not indicate the use of a waist belt. A review of the current physician's order indicated there was no order for the waist belt. Resident #9's medical record did not have a clear indication for the use of the waist belt. During an interview on 0[DATE] at 3:24 PM, Nurse Manager (NM) #1 reviewed the medical record and indicated she thought the resident wore the waist belt for safety. She stated the resident had a history of [REDACTED]. She stated the resident was able to release the belt independently. She verified there was no physician's order or care plan for the use of the waist belt. During a follow up interview on 0[DATE] at 4:21 PM, she stated up until a few weeks ago, the resident was able to release the waist belt independently. She stated her cognition had declined and she was no longer able to release the belt intentionally. NM #1 stated the resident was not able to get up on her own and required two-person assistance. NM #1 indicated it wasn't clear when the waist belt was implemented. During an interview on 01/30/20 at 9:46 AM, Minimum Data Set Nurse (MDS) #1 reviewed the resident's medical record and verified there was no care plan for the use of the waist belt. She stated whenever she collected the data for the MDS, the resident might have been ev… | 2020-09-01 |
| 31 | 31 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2020-01-29 | 759 | D | 1 | 1 | J64I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse(LPN) #1 on 1/28/20 at 12:10 PM revealed s/he crushed [MEDICATION NAME]/[MEDICATION NAME] 25/100 milligrams(mgs) and [MEDICATION NAME] [AGE] mg and placed each in the same cup. After entering Resident #118B's room, LPN #1 placed 30 cubic centimeters(cc) of water into each of two 30cc medication cups. LPN #1 placed approximately 10 cc of water from one of the medication cups containing water into the medicine cup containing the crushed medications. After checking and confirming placement of the [MEDEQUIP] tube([DEVICE]), LPN #1 placed approximately 20 cc of water into the [DEVICE]. Medications were placed in the [DEVICE], residual medication was observed and LPN #1 placed water from the second medication cup twice trying to administer all of the medication. During this time, a small amount of spillage was noted dripping off of LPN #1's glove. S/he placed the remaining water into the tube. Observation of the medication cup which contained the medications revealed medication was still in the bottom of the cup. LPN #1 confirmed the medication in the cup. LPN #1 stated s/he should have probably let the medicine sit a little longer to help the medications dissolve. Review of the facility policy titled Enteral Tube Medication Administration revealed the policy did not address residual medication. | 2020-09-01 |
| 1511 | 1511 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2020-01-24 | 550 | D | 1 | 0 | 46YX11 | Deficiency Text Not Available | 2020-09-01 |
| 4144 | 4144 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 584 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain a clean environment on 1 of 2 units observed. Soiled commode specimen collectors were observed stacked on top of each other on the floor in the shared bathroom for rooms [ROOM NUMBERS]. The findings included: During observation of the shared bathroom for rooms [ROOM NUMBERS], on 1/21/20 at 10:50 AM, 3 commode specimen collectors were observed on the floor in a corner, stacked on top of one another. The specimen collector at the top of the stack was smeared with a brown substance. The shared bathroom for rooms [ROOM NUMBERS] was observed again on 1/23/20 at 11:59 AM with Licensed Practical Nurse (LPN) #1 present. The 3 commode specimen collectors were observed stacked on top of each other in the same corner as observed on 1/21/20. The brown substance remained on the top specimen collector. LPN #1 confirmed the presence of the brown substance and specimen collectors stacked on the floor. LPN #1 stated any reusable medical supplies are to be cleaned after each use and stored in a bag. | 2020-09-01 |
| 4145 | 4145 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 607 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility files and policy, and interview the facility failed to implement their abuse policy and procedures related to an altercation between Residents #33 and #46, 2 of 2 sampled residents reviewed for abuse. The facility failed to report the incident to the appropriate State Agency and failed to conduct a complete and thorough investigation. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of nurse's notes on, 1/21/20 at 2:01 PM, revealed on 12/2/19 Resident #33 was in the dining room for the evening meal and displaying disruptive behavior. At some point, Resident #33 grabbed and squeezed Resident #46 on the arm. The residents were separated and Resident #33 was removed from the area. Resident #46 was evaluated by nursing following the incident and no injuries were found. Resident #33 was tested for and diagnosed with [REDACTED]. Review of the facility investigation of the incident, on 01/23/20 at 09:02 AM, revealed the incident was reported to the State Licensure Agency and not reported to the State Certification Agency. In addition, the facility failed to complete a thorough investigation of the incident. The facility investigation contained no witness statements and no statements from staff on duty at the time of the incident. During an interview with the Nursing Home Administrator (NHA), on 01/23/20 at 09:06 AM, the NHA confirmed the facility's investigation did not contain any statements from witnesses, staff on duty or the residents involved. The NHA also confirmed a thorough investigation was not completed. During another interview with the NHA, on 1/23/20 at 1:00 PM, the NHA stated the initial report and follow up reports should have been sent to the State Certification Agency, but were sent to the State Licensure Agency in error. The NHA stated the facility had recently been sold to another comp… | 2020-09-01 |
| 4146 | 4146 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 609 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility files and interview the facility failed to report a resident to resident altercation as a potential situation of abuse to the State Survey Agency involving Resident's #33 and #46, 1 of 2 sampled residents reviewed for abuse. The facility did not report the incident within 2 hours to the State Survey Agency and did not report the results of the investigation within 5 working days. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of nurse's notes on, 1/21/20 at 2:01 PM, revealed on 12/2/19 Resident #33 was in the dining room for the evening meal and displaying disruptive behavior. At some point, Resident #33 grabbed and squeezed Resident #46 on the arm. The residents were separated and Resident #33 was removed from the area. Resident #46 was evaluated by nursing following the incident and no injuries were found. Resident #33 was tested for and diagnosed with [REDACTED]. Review of the facility investigation of the incident, on 01/23/20 at 09:02 AM, revealed the incident was reported to the State Licensure Agency and not reported to the State Certification Agency. During an interview with the Nursing Home Administrator (NHA), on 1/23/20 at 1:00 PM, the NHA stated the initial report and follow up reports should have been sent to the State Certification Agency, but were sent to the State Licensure Agency in error. The NHA stated the facility had recently been sold to another company around the time of this incident. The NHA stated a great deal of change was taking place at the facility during this transition and this may have contributed to the error in reporting the incident. | 2020-09-01 |
| 4147 | 4147 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 610 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility files and interview the facility failed to thoroughly investigate a resident to resident altercation as a potential situation of abuse between Residents #33 and #46, 2 of 2 sampled residents reviewed for abuse. In addition, the results of the investigation were not reported to the State Survey Agency. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of nurse's notes on, 1/21/20 at 2:01 PM, revealed on 12/2/19 Resident #33 was in the dining room for the evening meal and displaying disruptive behavior. At some point, Resident #33 grabbed and squeezed Resident #46 on the arm. The residents were separated and Resident #33 was removed from the area. Resident #46 was evaluated by nursing following the incident and no injuries were found. Resident #33 was tested for and diagnosed with [REDACTED]. Review of the facility investigation of the incident, on 01/23/20 at 09:02 AM, revealed the incident was reported to the State Licensure Agency and not reported to the State Survey Agency. The facility also failed to complete a thorough investigation of the incident. The facility investigation contained no witness statements from staff or residents. In addition, there were no statements from staff on duty at the time of the incident. During an interview with the Nursing Home Administrator (NHA), on 01/23/20 at 09:06 AM, the NHA confirmed the facility's investigation did not contain any statements from witnesses, staff on duty or the residents involved. The NHA confirmed a thorough investigation was not completed. During another interview with the NHA, on 1/23/20 at 1:00 PM, the NHA stated the results of the investigation should have been sent to the State Survey Agency, but were sent to the State Licensure Agency in error. The NHA stated the facility had recently been sold to another company around the time of t… | 2020-09-01 |
| 4148 | 4148 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 655 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy, the facility failed to ensure that all patients had a completed baseline care plan with goals and preferences to include [MEDICAL TREATMENT] as a pertinent [DIAGNOSES REDACTED]. Resident # 146 had no physician order for [REDACTED].>The findings included: The facility admitted Resident #146 on 01/17/2020 with [DIAGNOSES REDACTED]. Record Review on 01/22/2020 at approximately 01:45 P.M. revealed Resident #146 was receiving [MEDICAL TREATMENT] at an outside center. Further review revealed no documentation that a Base Line Care Plan had been developed since her admission. Continued review revealed no evidence of [MEDICAL TREATMENT] as a current diagnosis. The medical record did not include Physician orders for [MEDICAL TREATMENT]. Interview with the Director of Nursing (DON) on 01/22/2020 at 01:45 PM, revealed that no orders had been written for [MEDICAL TREATMENT] and the Baseline Care Plan did not address [MEDICAL TREATMENT]. This statement was verified by the Licensed Practical Nurse (LPN) #1. Review of facility policy titled CARE PLANS-BASELINE on 01/23/2020 at 10:00 [NAME]M., revealed A baseline plan of care to meet the resident's immediate needs shall be be developed for each resident within forty-eight (48) hours of admission. | 2020-09-01 |
| 4149 | 4149 | EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY | 425409 | 706 PELZER HIGHWAY | EASLEY | SC | 29642 | 2020-01-24 | 698 | D | 0 | 1 | VVDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview and review of the facility's policy, the facility failed to ensure that all patients had a completed baseline care plan with goals and preferences to include [MEDICAL TREATMENT] as a pertinent [DIAGNOSES REDACTED]. Resident # 146 had no physician order for [REDACTED].>The findings included: The facility admitted Resident #146 on 01/17/2020 with [DIAGNOSES REDACTED]. Record Review on 01/22/2020 at approximately 01:45 P.M. revealed Resident #146 was receiving [MEDICAL TREATMENT] at an outside center. Further review revealed no documentation that a Base Line Care Plan had been developed since her admission. Continued review revealed no evidence of [MEDICAL TREATMENT] as a current diagnosis. The medical record did not include Physician orders for [MEDICAL TREATMENT]. Interview with the Director of Nursing (DON) on 01/22/2020 at 01:45 PM, revealed that no orders had been written for [MEDICAL TREATMENT] and the Baseline Care Plan did not address [MEDICAL TREATMENT]. This statement was verified by the Licensed Practical Nurse (LPN) #1. Review of facility policy titled CARE PLANS-BASELINE on 01/23/2020 at 10:00 [NAME]M., revealed A baseline plan of care to meet the resident's immediate needs shall be be developed for each resident within forty-eight (48) hours of admission. | 2020-09-01 |
| 848 | 848 | PEACHTREE CENTRE | 425095 | 1434 N LIMESTONE ST | GAFFNEY | SC | 29340 | 2020-01-23 | 604 | D | 0 | 1 | 17BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined the facility failed to ensure one of one (#[AGE]) sampled resident remained free from the use of a restraint imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility identified no additional residents with a restraint. The findings included: Resident #[AGE] had [DIAGNOSES REDACTED]. The resident's clinical record contained no documentation the resident exhibited symptoms of a medical condition/[DIAGNOSES REDACTED]. Resident #[AGE]'s quarterly assessment, dated 12/26/19, documented the resident was severely impaired in cognition and a trunk restraint was used daily while the resident was in a wheelchair (wc). A care plan, dated 06/25/19, documented the resident used a lap lock (buddy) while seated in a wheelchair (a lap buddy is a cushioned restraint that sits across the resident's lap and prevents the resident from rising). The care plan contained no additional information related to the resident's use of a restraint. A physician's orders [REDACTED]. An initial evaluation form for use of a physical restraint, dated 06/28/19, documented the reasons for the use of the restraint were the resident had falls and s/he had an unsteady gait. The evaluation also documented the family had requested the device be used when the resident was in the wheelchair due to frequent falls. The evaluation contained no documentation the resident exhibited symptoms of a medical condition/diagnosis, which would warrant the use of a restraint. On 01/22/20 at 8:25 a.m., the resident was observed in the dining room seated in a wheelchair, the lap buddy was in place. The resident was asked if s/he was able to remove the lap buddy, s/he did not respond. On 1/22/20 at 10:02 a.m., Activity Aide #1 propelled Resident #[AGE]'s wheelchair to the activities room/dining room. The lap buddy was still in place. The activity aide was asked why t… | 2020-09-01 |
| 142 | 142 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 689 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one of 17 residents (Resident #16) reviewed for altercations. Resident #16 continued to wander about the facility, including into other resident rooms, following four resident to resident altercations. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; did not wander; and ambulated independently. Review of facility investigations of resident to resident altercations revealed Resident #16 was involved in four of these incidents between 11/15/19 and [DATE]: On 11/15/19 at 04:00 PM, Resident #16 entered Resident #15's room and got into Resident #15's bed while Resident #15 was out of the room. When Resident #15 returned to the room and found Resident #16 in the bed, s/he asked Resident #16 to leave, and Resident #16 hit him/her in the face. On 11/20/19 at 06:00 PM, Resident #16 was again in Resident #15's bed. When Resident #15 asked Resident #16 to leave, Resident #16 hit Resident #15 with his/her shoe. The facility sent Resident #16 to the emergency room , where his/her [MEDICATION NAME] dosage was increased from 0.5 milligrams (mg) three times daily to 1 mg three times daily. On 11/25/19 at 02:15 PM, Resident #16 was ambulating in the hallway near the nurse's station, turned a corner, and encountered Resident #17, who was pacing near the nurse's station. Resident #16 struck Resident… | 2020-09-01 |
| 143 | 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects re… | 2020-09-01 |
| 2198 | 2198 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 607 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policy by failing to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner, failed to place potential perpetrators on leave during investigations, failed to ensure residents were interviewed during the course of the investigations, and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 resident's residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 01/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated, They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to reside… | 2020-09-01 |
| 2199 | 2199 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 609 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 residents residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 1/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to resident incident report that occurred on 01/14/19. Review of the facility's investigation record revealed the investigation into Resident #5's allegation of abuse was not initiated until 01/31/19 after the resident reported the allegation dire… | 2020-09-01 |
| 178 | 178 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 607 | D | 1 | 1 | FL9111 | > Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he … | 2020-09-01 |
| 179 | 179 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 609 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Residen… | 2020-09-01 |
| 180 | 180 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 625 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and [DATE] and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on [DATE] for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during December 2019. | 2020-09-01 |
| 181 | 181 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 908 | F | 1 | 1 | FL9111 | > Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine. | 2020-09-01 |
| 2024 | 2024 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 686 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of information from the National Pressure Ulcer Advisory Panel, the facility failed to accurately stage a pressure ulcer for one of one resident reviewed (Resident #6). The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review of the Wound Assessment Reports on 1/14/20 at approximately 1:47 PM revealed the following: -10/25/19-right buttock, .1 centimeters(cms) x .1 cm, Stage II, with scant, serous drainage, Slough [AGE]%, Granulation 20%; -1/6/20-right buttock, 1.8 cm x .8 cm, Stage II, serosanguineous, scant drainage, Granulation 100%; -1/13/20-right buttock, 1.5 x 1.2 cm, Stage II, sanguineous, scant drainage, Granulation 100%. During an interview with Registered Nurse #1 on 1/16/20 at 8:50 AM, s/he stated s/he had entered the role as Wound Care Nurse in September and would be going to more training related to wound care. S/he concurred the area on Resident #6's right buttock had been staged incorrectly and if slough was in the wound, the wound should have been staged as a Stage III pressure ulcer. Review of information from the National Pressure Ulcer Advisory Panel states the following: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis- . Granulation tissue, slough, and eschar are not present. | 2020-09-01 |
| 2025 | 2025 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 692 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Weight and Height Measurement, the facility failed to identify and implement additional interventions for one of 3 residents reviewed for nutrition. Resident #[AGE] with a documented weight loss of 11.28% at six months and a weight loss of 6.35% in one month. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Record review on 1/14/20 at 1:00 PM revealed a quarterly Minimum Data Set ((MDS) dated [DATE] listed Resident #[AGE] with impaired short and long term memory with severely impaired cognitive skills for daily living. Resident #[AGE] was coded needing extensive assistance-one person assist with eating. Review of the current physician orders revealed a Pureed diet, Ensure Plus daily, Magic Cup with lunch, evening snack, and a soft sandwich and nutty buddy as desired were ordered. Review of ordered medications revealed Resident #[AGE] had orders for [MEDICATION NAME] 40 mg daily and Potassium CL 10% (10 milliequivalants) every day. Review of the Medication Administration Records (MAR) for November 2019, December 2019, and January 2020 revealed with the exception of seven days Resident #[AGE]'s intake of Ensure was 100%. Intake for the Magic Cup varied from 0-100% during this time. Review of the meal percentage intake for three months revealed the resident's intake was 0-100%. Review of Resident #[AGE]'s weights revealed the following: 7/3/19- 133 pounds(lbs); 8/4/19-132 lbs; [DATE]-126 lbs; [DATE]-126 lbs; 12/11/19-118 lbs; 1/9/20-118 lbs; 1/16/20-122 lbs. Weight review revealed from [DATE]-12/11/19 there was a 6.35% weight lost and from 7/3/19-1/9/20 there was an 11.29% weight loss. Review of the Advanced Practice Registered Nurse (APRN) progress note dated [DATE] revealed a problem of loss of appetite with the onset of 7/19/18. Recorded weight by staff this month is back to 118 lbs. No further interventions were ordered. Revie… | 2020-09-01 |
| 2026 | 2026 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 759 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Nutrition Therapy, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 30 opportunities for error, resulting in a medication error rate of 6.67%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse (LPN) #1 on 1/15/20 at 12:33 PM revealed s/he crushed Sucrafate 1 Gram, [MEDICATION NAME] 20 milligrams (mgs), and [MED] 12.5 mg, placed each medication in individual cups and mixed each with water to help dissolve the medications. After administering medication through a [MEDEQUIP] tube to Resident #[AGE], LPN #1 was asked to show the medication cups to the surveyor. Residual medication was observed around the rim of the bottom of one cup and across the bottom of the second cup. The third cup appeared free of residual medication. During an interview with LPN #1 on 1/15/20 immediately after the observation, s/he confirmed there was residual medication in two of the cups and identified the medications as Sucrafate and [MED]. Review of the facility policy on 1/15/20 titled Enteral Nutrition Therapy, revealed the policy did not address residual medication. | 2020-09-01 |
| 2027 | 2027 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 812 | E | 0 | 1 | Z80E11 | Based on observations and interviews, the facility failed to ensure that ice machines in the main kitchen and the Cedar unit splash shield was free from stains, and that microwave ovens were free of dried stains on 2 of 3 units observed. The main kitchen ice machine splash shield was noted with dark stains, and the ice machine splash shield on Cedar unit was noted with stains. The microwave oven had dried on stains on inside top and bottom of microwave on Warley Unit and the microwave oven had dried stains on inside top on the Cedar Unit. The findings included: An observation and interview on 1/13/20 at approximately 10:08 AM with the facility's Chef confirmed the observation of the spots of black/brownish areas on the ice machine splash shield in the main kitchen. The Chef further stated that the spotted areas will not come out. The Chef stated it was the responsibility of maintenance to clean the ice machines. An interview on 1/13/20 at 11:33 AM with the Maintenance Director confirmed the blackened area on the ice machine splash shield in the main kitchen and stated the stains will not come out. The Maintenance Director stated he/she had to drain all the ice out of machine before cleaning the ice machines. An interview and observation on 1/13/20 at approximately 11:46 AM with the Maintenance Director confirmed the black/brownish stains on the ice machine splash shield on the Cedar Unit. Liquid was observed dripping from the splash shield to the ice in the machine. On 1/13/20 at approximately 4:19 PM, a review of the Unit Kitchen on Warley revealed the microwave had brown stains on inside top and bottom of the microwave oven. An observation and interview with Registered Nurse (RN) #2 confirmed the observation. RN #2 stated the stains at the bottom of the microwave occurred at lunch when coffee was heated. Reportedly, the housekeeping staff were responsible for cleaning the microwaves. On 1/13/20 at approximately 4:27 PM, a review of the Unit Kitchen/Staff Lounge on the Cedar Hall revealed the microwave had a thi… | 2020-09-01 |
| 2028 | 2028 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 849 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to monitor for coordination of services by a Hospice Care provider for 1 of 2 sampled residents reviewed for Hospice (Resident #[AGE]). The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Record review on 01/14/20 at approximately 3:20 PM revealed Resident #[AGE] elected Hospice benefits and was admitted to Hospice Care by physician's orders [REDACTED]. Review of the Hospice communication book maintained at the facility revealed the certification of Hospice Services and Hospice Care Plan had not been updated since the initial certification period. In an interview on 01/14/20 at approximately 3:53 PM, the Hospice Nurse confirmed no updated information was in the communication book and stated s/he did not know why the documents were not there. In an interview on [DATE] at approximately 8:52 AM, the Director of Nursing stated s/he was not aware the documents were not in the facility and confirmed that no one from the facility monitored to ensure the contracted services were being provided as agreed upon. | 2020-09-01 |
| 2029 | 2029 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 880 | D | 1 | 1 | Z80E11 | > Based on observation, interview, and facility policies titled Hand Hygiene and The Laundry Process, the facility failed to follow infection control procedures for one of one observation of the laundry. Staff was observed to touch the washer door with a soiled, gloved hand; and did not sanitize or wash hands after removal of face shield, goggles, and gown. In addition, staff was observed removing clean items out of dryer during sorting of linen, and a soiled basket was touching a clean basket. The findings included: Observation of the laundry on 1/15/20 at 9:15 AM revealed during the loading of the washer, Laundry Staff #1 touched the washer door with his/her soiled, gloved hand. After removal of his/her face shield, goggles, and gown, Laundry Staff #1 did not sanitize hands or wash hands. In addition, staff was observed during the sorting of the linen, to remove clean linen out of the dryer. Further observation of the laundry revealed a dirty cart was touching a clean cart. During an interview with Laundry Staff #1 immediately after the observation, the above concerns were shared. Laundry Staff #1 did not dispute the findings and stated the washers were sanitized after every third wash. Review of the facility policy titled Hand Hygiene revealed it did not address handwashing after removal of face shield, goggles, and gown. Review of the facility policy The Laundry Process revealed it did not address the above concerns. | 2020-09-01 |
| 2841 | 2841 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2020-01-16 | 609 | D | 1 | 0 | 1I3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to report an allegation of verbal abuse within 2 hours after the allegation was made for Resident #1, 1 of 3 sampled residents reviewed for Abuse. The allegation was reported to facility staff on [DATE]20 and reported to the State Agency on [DATE]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 1/15/2020 at 2:20 PM, revealed on [DATE] the facility received a phone call from a family member of Resident #1 alleging verbal abuse. As part of the investigation, the facility interviewed Resident #1 who stated the alleged verbal abuse occurred on the night shift on [DATE]. The facility also interviewed all staff members on duty at the time of the allegation as part of the investigation. Review of a hand written statement signed by Certified Nursing Assistant (CNA) #1 revealed Resident #1 reported the alleged verbal abuse to her/him on [DATE]20. Review of a signed statement by Registered Nurse (RN) #1 revealed RN #1 interviewed Resident #1 about the allegation on [DATE]. CNA #1 was present during the interview and stated Resident #1 reported the allegation to her/him on [DATE]20. During an interview with the Director of Nursing, on 1/16/2020 at 11:46 AM, the DON stated s/he also interviewed CNA #1 who confirmed Resident #1 had reported the allegation to her on [DATE]20. The DON stated staff are educated monthly and after any alleged violation about reporting potential abuse immediately to their supervisor. During an interview with RN #1, on 1/16/2020 at 1:45 PM, RN #1 confirmed her statement from [DATE] and stated CNA #1 said Resident #1 reported the allegation to her/him on [DATE]20. CNA #1 could not be reached by phone for interview. | 2020-09-01 |
| 3221 | 3221 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 609 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and policy review, the facility failed to report an allegation of misappropriation of resident property for Resident #82 to the State Survey Agency within the required timeframe of 24 hours. This failure was found for one (1) of seven (7) facility self-reported incidents reviewed during the survey. Findings include: Review of Resident #82's record indicated the resident's original admitted was [DATE]. The resident's [DIAGNOSES REDACTED]. According to Resident #82's Significant Change Minimum Data Set (MDS) assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Resident #82 required assistance with activities of daily living (ADLs). The Inventory of Personal Effects form completed on [DATE] indicated Resident #82 had a gold ring in his/her possession when s/he was admitted to the facility. Review of the Concern Grievance Form dated [DATE] and completed by the Director of Social Services revealed Resident #82's son reported the concern/grievance on [DATE]. The son indicated Resident #82's wedding ring was missing. The son and family did not know exactly when it went missing. Documentation on the Concern/Grievance Form revealed it most likely fell off Resident #82's finger without him/her realizing it. The Administrator, Director of Nursing and Housekeeping staff were notified of the missing ring on [DATE]. The family was asked for photographs of the ring. A search for the ring was conducted in Resident #82's room and bathroom, in the spa, and in the vacuum cleaner bag (went through its contents). The search did not result in finding the ring. The report indicated the plan also included checking the trap in the vacuum cleaner, checking the resident's robes, laundry washers and dryers, and his/her recliner. The ambulance transport company was contacted … | 2020-09-01 |
| 3222 | 3222 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 638 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for one (1) of 18 sample residents (Resident #82). Findings include: Review of Resident #82's record indicated the resident's original admitted was 12/22/15. The resident's [DIAGNOSES REDACTED]. According to the resident's Significant Change MDS assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Under the Mood Section, the resident was noted with tiredness/having little energy. She had no behavioral indicators. The resident required assistance with activities of daily living (ADLs). The MDS indicated the resident required extensive assistance from staff for transfers, dressing, and toilet use. Review of the clinical record revealed the last two (2) Quarterly MDS assessments with Assessment Reference Dates (ARD) of 9/12/19 and 12/5/19 were incomplete. The 9/12/19 and 12/5/19 Quarterly MDS sections were blank (no data entered) for the following sections: C - Cognitive Patterns and D - Mood. Section Z - Assessment Administration was not signed off. The 9/28/19 and 12/5/19 Quarterly MDS were incomplete as follows: Section C - The Cognitive Patterns section was blank for the Brief Interview for Mental Status (BIMs), the Staff Interview for Mental Status, and the [MEDICAL CONDITION] Section. There was no determination of the resident's level of cognition. Section D - The Mood section was blank for the Resident Mood Interview, Staff Assessment of Resident Mood, and Total Severity Score. There was no assessment of the resident's mood. The 9/12/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/16/2020 (as late as three (3) months after the ARD (annual review date). However, the overall assessment had not been signed of… | 2020-09-01 |
| 3223 | 3223 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 640 | E | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessments were encoded and transmitted to C[CONDITION] (Centers for Medicare and Medicaid Services) according to State and Federal time frames for five (5) of 18 sampled residents (Resident #2, Resident #82, Resident #132, Resident #133, and Resident #182). This deficient practice placed the residents at risk for having incomplete care plans and inadequate care and services resulting in physical and psychosocial decline. Findings include: Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected that the facility had not submitted assessment information into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System as required for the following residents. 1. Record review of Resident #2's face sheet revealed that Resident #2 was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 7/28/19 for Resident #2, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #2's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 2. Record review of Resident #82's face sheet dated reflected Resident #82 was admitted to the facility on [DATE]. Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of [DATE] for Resident #82, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #82's Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 3. Record review of Resident #132's face sheet dated reflected the resident was admitted t… | 2020-09-01 |
| 3224 | 3224 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 657 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure care plans for two (2) of 18 sampled residents (Resident #2 and Resident #5) were updated when changes in condition occurred. This failure delayed a reduction in antipsychotic medication and possible lack of wound care and bleeding precautions. Findings include: 1. Record review of Resident #2's face sheet dated 1/26/2020 reflected that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted with medications including Quetiapine (an antipsychotic) and [MEDICATION NAME] (an antidepressant). Record review of the resident's Minimum Data Set ((MDS) dated [DATE] assessed the resident as having minimal cognition impairment as indicated the Brief Interview for Mental Status (BI[CONDITION]) score of 13. The resident was not documented as receiving hospice services or antipsychotic medications. Record review of Resident #2's active Care Plan dated 7/8/19-present reflected that Resident #2 was actively care planned for hospice services and care planned for monitoring of antipsychotic medication side effects. Care plan notes reflected a request for hospice consult on 8/15/19 by the family. Record review of a physician order [REDACTED]. The orders reflected a certification start date of hospice services dated 8/20/2019. The care plan was not updated/revised to reflect the physician orders [REDACTED]. During an interview on 1/15/2020 at 5:45 PM the facility Medical Doctor (MD) stated that he did not know that Resident #2 was no longer on hospice services. He stated that if he had known that he would have attempted a Gradual Dose Reduction (GDR) of Resident #2's antipsychotic if indicated. He stated that when a resident is on hospice care that he treats the resident very differently with respect to diagnostic orders because the resident is being followed by hospice, and if the resident comes off of hospice, then he would order primary care d… | 2020-09-01 |
| 3239 | 3239 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 656 | E | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, clinical record reviews and facility policies, the facility failed to create and implement comprehensive care plans for five (5) of 20 sampled residents (Residents #10, #22 #46, #55, and #[AGE]). The facility did not implement the care plan for restorative services for Resident #10 who was assessed to require passive range of motion restorative services. The facility did not develop a comprehensive care plan for the use of a Foley catheter for Resident #22. The facility failed to develop an individualized and comprehensive care plan for Resident #46's range of motion (ROM) services, catheter use, and pressure ulcer care. The facility did not update the care plan with the Wound Care Consultant (WCC) recommendations to keep Resident #55 incontinence brief unlatched when the resident was in bed. The facility did not develop a comprehensive care plan for the use of a Foley catheter for Resident #[AGE]. Findings included: Review of the policy titled, Person-Centered Care Plan Process dated 10/19/17 revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of Resident #10's clinical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had short and long-term memory problems and severely impaired decision-making skills. The MDS revealed Resident #10 had impairment on one (1) side of the lower extremity and did not use a mobility device. The MDS documented the resident did not receive therapy or restorative services. Review of Resident #10's care plan dated 11/6/19 for activities of daily living (ADL) function included the interventions, therapy as o… | 2020-09-01 |
| 3240 | 3240 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 657 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to ensure comprehensive care plans all residents were invited to care plan meetings. Resident #3 stated during an interview that he/she used to be invited to care plan meetings, but was no longer being invited to attend. An interview with the MDS (Minimum Data Set) nurses revealed they were responsible for inviting residents and family members to care plan meeting and they do not invite residents to their care plan meeting unless their cognitive status is assessed to be intact. The findings include: Review of the facility policy, with revision date of 10/17/19 Person Centered Care Plan Process, revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident in regard to daily routines and preferred activities. Residents will remain actively engaged in his or her care planning process through the resident's rights to participate in the development of the care plan and be informed in advance of changes to the care plan. Review of Resident #3's clinical record revealed an admitted to the facility of 7/9/12. The resident's [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Dysphagia, Hypertension, [MEDICAL CONDITION], Anxiety and Depression. Resident #3's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, was able to express ideas and wants, usually understands others and vision was adequate with c… | 2020-09-01 |
| 3241 | 3241 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 684 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interviews, and review of facility policy, it was determined the facility failed to follow the wound care consultant's (WCC) recommendation to keep the brief unlatched when in bed and failed to assess and measure the wound every week for one (1) resident. (Resident #55) Findings included: Review of the policy titled, Wound Evaluations revised 9/7/17 revealed an evaluation of wounds will be performed on admission, weekly and on discovery. Objective evaluation components included: location/type of wound; measurements; appearance; drainage; odor; presence of undermining/tunneling; healing; pain; [MEDICAL CONDITION]; presence of infection. Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Admission Observation form dated 12/13/19 and timed 5:47 PM revealed the resident had no alterations in skin, except for excoriation on the coccyx. Review of Resident #55's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, indicating intact cognition. The MDS revealed the resident required total assistance with transfers and personal hygiene. The resident was always incontinent of bowel and bladder, was at risk for developing pressure ulcers and had no skin alterations. Review of Resident #55's care plan dated 1/8/2020 identified the resident was admitted with excoriation to the sacrum and peri area. The interventions included nursing to do a full body audit weekly, preventative skin care as ordered, Certified Nurse Aides' (CNAs) to assess skin with activities of daily living (ADL) care and report any changes to nurse. Review of the Skilled Charting notes revealed: [DATE] at 6:49 PM the resident had no alteration in his skin. [DATE] at 2:35 AM and at 10:43 AM the resident had no alteration in skin. 12/30/19 at 10:43 AM the resident had no alteration in skin. 12/31/19 at… | 2020-09-01 |
| 3242 | 3242 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 686 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility policy it was determined the facility failed to provide appropriate wound care for one (1) of five (5) residents sampled for pressure ulcers. Resident #46. Findings included: Review of the policy titled, Indications For Glove Use, dated 11/27/17 documented, hands are washed immediately after gloves are removed, before contact with another resident or the environment and hands are washed or decontaminated prior to donning gloves. The facility did not provide a policy for the process and completion of dressing changes, upon request. Review of the clinical record for Resident #46 revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of Resident #46's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 14 (indicating intact cognition). The resident required total assistance of two (2) people with bed mobility, dressing, and toilet use and required total assistance of one (1) staff for eating, personal hygiene and bathing. The resident had one (1) Stage 3 and two (2) Stage 4 pressure ulcers. Review of Resident #46's care plan, dated 12/31/19, documented the interventions for impaired skin integrity as treatments per physician's orders and see Treatment Administration Record (TAR) for updated treatments. Review of the 1/2020 Physician Orders revealed an order dated [DATE] for two (2) times a day to cleanse the left exterior malleolus wound with Acetic Acid, apply a thin layer of Medi-Honey (used to treat wounds and has antibiotic in it), cover with [MED] (absorbent dressing), a dry dressing and secure with [MEDEQUIP]. The Physician's Orders also revealed an order dated 12/11/19 for two (2) times a day to clean the wound on the sacrum with Acetic Acid, apply a thin layer of Medi-Honey, and cover with [MED] and a dry dressing. Observation on 1/15/2020 at 11:47 AM during Resident #46's wound … | 2020-09-01 |
| 3243 | 3243 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 688 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation record review, interviews, and review of facility policy, it was determined the facility failed to provide restorative services for three (3) of seven (7) residents sampled for Range of Motion (ROM) services. (Resident #10, Resident #39, Resident #46) Findings included: Review of the policy titled, Joint Mobility/Range of Motion Program and Splinting-Initiating the Program dated 1/1/2020, documented a restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy. The restorative aide should review the care plan to determine the following: active or passive ROM, body parts to be exercised; number of repetitions; and special instructions. After the exercise session, the restorative aide should report any changes immediately, document any changes and document completion of the program and time. 1. Review of Resident #10's clinical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had short and long-term memory problems, had severely impaired decision-making skills and exhibited disorganized thinking that fluctuated. The resident required extensive assistance of one (1) with bed mobility, toileting, personal hygiene and dressing. The resident did not transfer from the bed or ambulate. The MDS revealed Resident #10 had impairment on one (1) side of the lower extremity and did not use a mobility device. The MDS documented the resident did not receive therapy or restorative services. Review of Resident #10's care plan dated 11/6/19 for activities of daily living (ADL) function included the interventions: therapy as ordered per physician's orders [REDACTED]. Review of the Physical The… | 2020-09-01 |
| 3244 | 3244 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 689 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and clinical record review, the facility failed to ensure one (1) of three (3) residents (Resident #48) reviewed for accidents had devices in place to reduce injury in case of an accident. Resident #48 was to have a low bed and floor mats on both sides of the bed. Resident #48 was not in a low bed and had only one floor mat during four (4) observations. Findings included: Review of Resident #48's clinical record revealed an original admission on 4/16/19 and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's significant change Minimum Data Set ((MDS) dated [DATE] revealed she was usually understood and usually understands others. The MDS indicated she had severely impaired decision making. The MDS noted she needed extensive assistance of two people to move in bed and to transfer, extensive assistance of one person for locomotion on and off the unit, and had limited range of motion on one side of her body on both her upper and lower extremities. The MDS indicated she had two (2) falls with major injuries since the prior assessment. Review of Resident #48's comprehensive care plan updated [DATE] revealed she was at risk for falls related to her impaired balance during transitions, the use of antidepressant medication and cognitive impairment. The care plan noted she had a fall on 9/15/19. Interventions included floor mats on both sides of the bed. Review of Resident #48's 1/2020 physician orders [REDACTED]. Observations on 1/13/20 at 3:14 PM, 1/14/20 at 10:00 AM, 1/15/20 at 1:10 PM, and 1/16/20 at 11:39 AM revealed Resident #48 in bed. There was a floor mat on left side of bed and the bed was in a waist high position, not in the lowest position. In an interview on 1/16/20 at 05:26 PM, Unit Manager #1 stated Resident #48 should have floor mats on both sides of the bed. She confirmed there were orders for the resident to have the bed in a low position. The facility failed to ensure f… | 2020-09-01 |
| 3245 | 3245 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 690 | G | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, clinical record reviews and facility policy review, the facility failed to ensure three (3) of four (4) residents (Residents #22, #46, and #[AGE]) reviewed for catheter care received care and services for indwelling Foley catheters in a manner to prevent urinary tract infections. The facility failed to have current treatment orders for the Foley catheter and the catheter was not anchored, Resident #22 suffered blood in his urine and had three (3) bacterial infections that were not identified prior to surveyor intervention. This failure led to Resident #22 experiencing actual harm. 1. Resident #22's Foley catheter was not anchored to prevent pulling, had no current physician's orders [REDACTED]. The resident's catheter was not anchored to prevent pulling or injury. The facility staff was unaware of the red colored urine with sediment in the resident's drainage bag until pointed out by the surveyor. Therefore this standard is cited at harm level. 2. Resident #46's Foley catheter was not anchored or maintained in a dignity bag. 3. Resident #[AGE]'s Foley catheter was not anchored or maintained in a dignity bag. Findings included: Review of the policy titled, Catheter-Urinary Catheter, Cleaning and Maintenance dated 7/1/16 revealed the policy lacked documentation regarding the anchoring of the catheter tubing to the resident to prevent pulling on the urethra. 1. Review of Resident #22's face sheet dated 1/13/2020 revealed he/she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident sometimes understood others and was sometimes understood. Resident #22 had severely impaired cognition. The MDS noted Resident #22 had an indwelling urinary catheter. Review of Resident #22's comprehensive care plan updated 11/14/19 revealed he/she used a Foley catheter due to [MEDICAL CONDITION] bladder. Interventions included to change Foley/bag as… | 2020-09-01 |
| 3246 | 3246 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 759 | E | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and review of facility policy, it was determined the facility failed to administer medication as ordered and/or following standards of practice for two (2) of four (4) residents of the sample. (Resident #24 and Resident #68) The medication error rate was 27.78 percent. Findings include: 1. Observation of the medication pass for Resident #24 on 1/14/2020 at 9:00 AM revealed Licensed Practical Nurse (LPN) #5 gave the resident [MEDICATION NAME] (used to treat too much acid production in the stomach) 10 milligrams (mg) by mouth. Review of the physician's orders [REDACTED]. Further review of the resident at 9:00 AM revealed Resident #24 had already had her breakfast. Review of the 1/2020 Medication Administration Record [REDACTED] Interview with LPN #5 on 1/14/2020 at 2:40 PM revealed the [MEDICATION NAME] should be given prior to breakfast. Interview with the Assistant Director of Nursing (ADON) on 1/14/2020 at 4:34 PM revealed the Unit Managers or the ADON are supposed to check the Physicians Orders against the MARs at the first of the month to ensure accuracy. Scheduling the [MEDICATION NAME] at 9:00 a.m. would be scheduling it for after breakfast. The time needs to be changed to prior to breakfast. The facility failed to administer the [MEDICATION NAME] per the physician's orders [REDACTED]. 2. Observation of the medication pass for Resident #68 on 1/14/2020 at 9:39 AM revealed Registered Nurse (RN) #5 prepared the following nine (9) medications: [REDACTED]. Further during the medication preparation revealed RN #5 placed an unmeasured amount of water into the plastic cup that contained the 30 milliliters (ml) of Critical Care. The mixture was thick like honey. The other medications were crushed and placed in a glass of water. RN #5 then entered the resident's room, turned off the [MEDEQUIP] feeding. She then checked the [DEVICE] for residual, attached the syringe and poured in the crushed pills … | 2020-09-01 |
| 3247 | 3247 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 803 | F | 1 | 1 | SMCX11 | > Based on observations, interviews, facility menu reviews and facility policy reviews, the facility failed to provide portions of food as required on the dietitian approved menu for one (1) of two (2) meals observed (lunch meal 1/15/20) Seventy-three residents ate food from the kitchen. 1. The vegetable lasagna was not portioned correctly for residents receiving regular and mechanical soft meals. 2. The vegetable lasagna was underserved for residents receiving a pureed diet. Findings included: 1. Observation on 1/15/20 at 12:00 PM revealed Cook #1 begin serving the lunch meal. Cook #1 took a spatula and cut the regular and mechanical soft vegetable lasagna into squares. She did not measure the portions of the lasagna, and the squares of lasagna were different sizes. She put one square on a plate. When the spatula did not cut the square completely, a layer of noodles would be pulled out and left in the tray. In an interview on 1/15/20 at 12:43 PM, Cook #1 stated she served one square of lasagna to each resident. Review of the menu printed 1/13/20 revealed residents receiving a regular diet and a ground/minced/moist were to receive 6 ounces of lasagna. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager (CDM) confirmed the lasagna was not portioned out. She said Cook #1 could have used a scoop to ensure the correct size was used. 2. Observation on 1/15/20 at 12:00 PM reveled Cook #1 serving lunch. Cook #1 scooped one (1) scoop of pureed vegetable lasagna for residents on a puree diet. In an interview on 1/15/20 at 12:43 PM, Cook #1 stated she used one (1) scoop of a #10 scoop (3.25 ounces) for the residents receiving a pureed diet. Review of the menu printed 1/13/20 revealed residents receiving a pureed diet were to receive a number six (#6) scoop (5.33 ounces) portion of lasagna. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager (CDM) confirmed a #10 scoop was too small a portion for residents receiving a pureed diet. Review of facility's Nutrition Policies and Procedures Foo… | 2020-09-01 |
| 3248 | 3248 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 804 | E | 1 | 1 | SMCX11 | > Based on observations, interviews, and facility policy reviews, the facility failed to provide flavorful and palatable food as required for one (1) of two (2) meals observed (lunch meal 1/15/20) Seventy-three residents ate food from the kitchen. The green beans served did not have any seasoning or flavor. Findings included: In a resident group interview on 1/14/20 at 10:47 AM, seven (7) of seven (7) residents said they felt the green beans were bland and did not taste good. Observation on 1/15/20 at 12:00 PM revealed Cook #1 begin serving the lunch meal. Cook #1 served green beans to residents on a regular and mechanical soft diet. A test tray of a regular diet meal was tasted on 1/15/20 at 1:06 PM with the Certified Dietary Manager (CDM). The green beans tested did not have any seasoning and tasted like green beans boiled in water. In an interview on 1/15/20 at 1:10 PM, the CDM confirmed the green beans needed seasoning, that they tasted like cooked frozen green beans. Review of facility's Nutrition Policies and Procedures Food Preparation revised 10/2/17 noted 5. Batch cook vegetables to conserve nutrient value and maintain flavor and color. | 2020-09-01 |
| 3249 | 3249 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 812 | F | 1 | 1 | SMCX11 | > Based on observations, interviews, and facility policy review, the facility failed to prepare and serve food in a sanitary manner for one (1) of two (2) meals observed (lunch 1/15/20). Seventy-three residents ate food from the kitchen. 1. Cook #1 wore a bracelet with charms that hung down while she prepared and served the lunch meal. 2. Cook #1, Dietary Aide #1, and the Certified Dietary Manager did not wash their hands or change gloves when touching other items in the kitchen and before serving the meal. 3. The Certified Dietary Manager did not sanitize a divided plate for the required amount of time that was used for service. Findings included: 1. Observation on 1/15/20 at 11:16 PM revealed Cook #1 preparing the lunch meal. On her right wrist, she wore a silver bracelet with charms that hung down. She then served the lunch meal. She wore gloves but the gloves did not cover the bracelet. In an interview on 1/15/20 at 12:46 PM, Cook #1 confirmed she wore a bracelet on her wrist. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager confirmed bracelets should not be worn in the kitchen. Review of facility's Nutrition Policies and Procedures Dress Code revised 10/2/17 noted 3. Neat and clean appearance. Limited jewelry: unadorned rings that are easily cleaned/removed during hand hygiene procedure, watch and non-dangling earrings only. Per the USDA Food Code, employees may not wear jewelry on their arms and hands during food preparations except for a plain ring such as a wedding band. 2. Observations on 1/15/20 of the lunch meal service revealed the following: - 12:06 PM, Dietary Aide (DA) #1 opened the kitchen door wearing gloves, removed her gloves, did not perform hand hygiene/wash her hands, donned new gloves and continued serving lunch onto trays. - 12:09 PM, Cook #1 opened the wooden oven doors with gloved hands, pulled out the lasagna, and closes the oven door. She continues serving without changing gloves or washing her hands. - 12:22 PM, the Certified Dietary Manager (CDM) picked up the bi… | 2020-09-01 |
| 4002 | 4002 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 550 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility documents, the facility failed to ensure one (1) of 20 sampled residents was provided dignity in the provision of services. Resident #61 requested not to be provided care by Certified Nursing Aide (CNA) #8. Responsible nursing staff did not provide follow-up to determine the cause of Resident #61's request. CNA #8 continued to enter Resident #61's room against the resident's request. The findings included: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to receive care from the center in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality .You have the right to reside and receive care in the center with reasonable accommodations of individual needs and preferences except when your health and safety or the health and safety of other patients/residents would be endangered .You have the right to receive care, treatment and services that are adequate and appropriate and provided: d. With respect for your personal dignity and privacy. Resident #61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had mild symptoms of depression and had no documented behavioral symptoms. Resident #61 require extensive assistive of one (1) staff person for bed mobility, dressing, toileting and personal hygiene. Resident #61 was always incontinent of bowel and bladder. Review of The Care Area Assessment (CAA) of the MDS revealed behavioral symptoms were not triggered and not moved forward to the comprehensive care plan. Review of Resident #61's Self-Care Deficit/Activities of Daily Living (ADL) care plan dated [DATE] revealed the resident had a self-care deficit due to impaired mobility and function… | 2020-09-01 |
| 4003 | 4003 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 655 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to develop and implement a baseline care plan for one (1) of 43 sampled residents that included the instructions needed to provide effective and person-centered care that met professional standards of quality care within 48 hours of the resident's admission for Resident #1. The findings included: The facility provided the policy titled Care Plans dated 12/31/96 which directed, It is the policy of the health care center for each patient/resident to have a person centered baseline care plan .Baseline care plan must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. 1. Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT (Interdisciplinary Team), the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required total assistance of one (1) staff for bathing, and the resident felt that it was somewhat important for him/her to choose between a tub bath, shower, bed bath or sponge bath, (although during interview, the resident stated nobody asked him/her about his/her preferences). The resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, d… | 2020-09-01 |
| 4004 | 4004 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 656 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a person-centered, comprehensive care plan was implemented for two (2) of 20 sampled residents (Resident #68 and Residents #[AGE]). Licensed nursing staff did not provide Resident #68 nail care as directed in the resident's plan of care. Observations on 1/13/20 and 1/14/20 of Resident #[AGE] revealed skin integrity care planned interventions were not followed related to suspending heels in bed and applying Prevalon boots to both feet when in bed. The findings include: Record review of the facility policy titled, 'Care Plans, dated 12/31/96, revealed it is the policy of the health care center for each resident to have a person centered comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the resident choice. Further review revealed the care plan approaches served as instructions for the resident's care and provides continuity of care by all partners. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the Certified Nursing Assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record. Review of Resident #68's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behavioral symptoms and required total assistance of staff for personal hygiene and bathing. Resident #68's Quarterly MDS dated [DATE] noted the resident required extensive assistance for personal hygiene and bathing. According to Resident #68's Activities of Daily Living (ADL) care plan date… | 2020-09-01 |
| 4005 | 4005 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 677 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy, it was determined the facility failed to provide the necessary services to provide and/or maintain activities of daily living (ADLs) related to personal hygiene and/or bathing for three (3) of 20 sampled residents (Residents #26, #34 and #68). Resident #26 requested but did not receive a shower between August 2019 and January 1, 2020. The resident was provided bed baths only. Resident #34 was assessed as extensive assistance with one (1) person for personal hygiene; however, staff failed to provide weekly showers as scheduled on Tuesday, Thursday and Saturdays. Resident #34 had not had a documented shower since 11/12/19 during the day shift. Resident #68 did not receive assistance with nail care when the resident's nails were long and jagged. The findings include: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to: c. Make choices about aspects of your life in the nursing center that are significant to you. Review of a policy entitled Documentation: Charting Activities of Daily Living (ADLs) (reviewed 10/24/18) revealed a policy statement that it is required for ADL care given by Certified Nursing Assistants (CNAs) and nurses to be documented using the CNA ADL Flow Sheet Form. For facilities with smart charting, all documentation will be completed using the smart charting system. During interview on 1/16/2020 at 3:47 PM, the Director of Health Services (DHS) stated the facility did not have a policy for bathing a dependent resident. Resident #26 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of Resident #26's annual Minimum Data Set (MDS) Assessment, dated [DATE] revealed a brief interview for mental status score of 13, indicating the resident was independent in cognitive skills for daily decision making. Resident #26 was identified on the assessment to have no sy… | 2020-09-01 |
| 4006 | 4006 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 684 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of facility policy, the facility failed to ensure two (2) of 20 sampled residents received services in accordance with professional standards (Resident #68 and Resident #[AGE]). Resident #68 did not receive therapy services to assess the resident for an appropriate-sized geri-chair. Facility nursing staff did not observe, assess, document and treat two (2) wounds for Resident #[AGE]. The findings included: Review of the facility's Therapy Evaluations policy last revised 9/3/15 revealed Therapy will foster an interdisciplinary approach to care by educating departments on safe transfer techniques, environmental adaptations, and patient/resident specific restorative nursing programs as indicated. Review of Resident #68's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behavioral symptoms and required extensive to total assistance of staff for all activities of daily living (ADLs). The resident had impairment of upper and lower bilateral extremities. According to the assessment, the resident did not utilize a device for mobility, and did not receive therapy services. Resident #68's Quarterly MDS dated [DATE] had not significantly changed from the annual assessment. Review of Resident #68's 4/24/19 comprehensive care plan, revealed Resident #68 had care areas that included: Resident #68's potential for skin breakdown due to decreased mobility, incontinence, [MEDICAL CONDITION] left side [MEDICAL CONDITIONS], [MED] dependent DM II. One approach to address this area was to turn and reposition frequently (4/24/19). Resident #68 was dependent with care givers in all ADL needs due to history [MEDICAL CONDITION] left [MEDICAL CONDITION]. Approaches included: anticipate and meet ADL needs, incontinent care needs and encourage resident to be up … | 2020-09-01 |
| 4007 | 4007 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 686 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents with pressure ulcers received necessary care and services to promote healing and prevent new ulcers from developing for one (1) of six (6) residents identified with pressure ulcers out of a total sample of 20 residents. Resident #[AGE]'s Certified Nursing Assistant plan of care directed staff to suspend the heels in bed and apply Prevalon boots (soft comfortable boot designed to keep the heel off the mattress to relieve pressure for individuals spending a lot of time in bed) to both feet when in bed for impaired skin integrity. However, observations on 1/13/2020 and 1/15/2020 revealed pillows under Resident #[AGE]'s calves and feet as well as the Prevalon boots were not on the resident's feet. The findings include: Review of the facility policy titled, Pressure Ulcer Prevention Program, dated September 2015, revealed a pressure ulcer prevention program is in place at each health care facility to identify residents at risk for developing pressure ulcers which is determined utilizing the Braden Scale for Predicting Pressure Score Risk. Any resident who is identified with a Braden score of 18 or below should be placed on the Pressure Ulcer Prevention Program. The Program consists of the following interventions: Reassess risk for all residents with specified intervals; inspect skin of all at risk residents daily with ADLs; manage moisture by providing incontinence care if indicated; optimize nutrition/hydration; minimize pressure by turning and repositioning, therapeutic support surface assessment, therapeutic seating surface assessment and tissue tolerance assessment; care plan should address resident interventions implemented when on the program; resident/family teaching regarding the program; and establish an interdisciplinary team when meets at least weekly to review resident care needs and outcomes. Review o… | 2020-09-01 |
| 4008 | 4008 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 692 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility policy, the facility failed to initiate approaches to prevent further weight loss for one (1) of 20 sampled residents (Resident #66). Resident #66 had a 4.4% weight loss in 10 days and the Nurse Practitioner and Registered Dietician recommendations to address the weight loss were not initiated. The findings were: Review of the facility's Weight Monitoring Program last revised 6/13/18 noted residents who experience significant weight loss will be weighed weekly and reviewed weekly for a minimum of four (4) weeks until weight is stable or increasing .A significant weight change is identified as: 5% weight loss or gain in one month; 7.5% weight loss or gain in three months; and 10% weight loss or gain in six months .All disciplines should be aware of all patients/residents who are on a weight monitoring program. Resident #66 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired and required total assistance of staff for eating. According to the assessment the resident was 58 inches in height and weighed 112 pounds (lbs), during the assessment period. Review of Resident #66's Nutrition care plan dated [DATE], Resident #66 was at risk for decline in nutritional status related to increased nutrient needs for wound healing, dependent on staff for feeding, has poor appetite and low [MEDICATION NAME] with [DIAGNOSES REDACTED]. Approaches - follow colored napkin protocol; provide supplements as ordered; provide diet as ordered; ST (speech therapy) to evaluate and treat per physician's (MD) order; weigh and observe result, notify MD/IDT (interdisciplinary team) of significant weight changes. Review of Resident #66's History & Physical (H&P) dated 9/18/19 noted that the resident entered the facility with severe protein malnutrition. Review o… | 2020-09-01 |
| 4009 | 4009 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 697 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to assess pain and provide pain relieving measures for one (1) of 43 sampled residents, Resident #1. The findings included: The facility provided the policy titled, Pain assessment dated [DATE] directed, At all levels of health care, the standard for performing a complete pain assessment is: on admission .with any self-report of pain or evidence of pain .whenever a pain score is above 0 (zero) . Complications: When left untreated, pain can have negative consequences, including multisystemic complications and the development of chronic disabling pain, which may seriously impact the patient's functioning, quality of life, and well-being . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] recorded Resident #1 had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #1 had impairment on both upper extremities. The MDS recorded the resident had occasional pain and rated the intensity as four (4) of 10, with 10 being the worst pain. The MDS recorded Resident #1 Received prn (as needed) pain medication or was offered and declined. Resident #1's clinical record lacked a baseline care plan for pain. The care plan developed on 1/14/20 for pain included the following interventions: Administer pain medications per physician's orders [REDACTED]. Monitor effectiveness of pain medication Provide comfort measures (no specific comfort measures listed) Report to physician if resident does not experience reduction or relief of pain after receiving interventions through next 30 days Complete Pain Observation on admission and as needed Review of the Admission Pain Interview and Obse… | 2020-09-01 |
| 4010 | 4010 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 698 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to assess and monitor the fistula access port for [MEDICAL TREATMENT] for one (1) of two (2) residents sampled for [MEDICAL TREATMENT]. Resident #1. The findings included: The facility provided the policy titled, [MEDICAL TREATMENT] Care - Pre and Post [MEDICAL TREATMENT] dated 5/25/18 which directed, Pre-[MEDICAL TREATMENT]: Verify Physician Orders. Take and record patient/resident blood pressure and pulse and observe shunt access (AV shunt or Permacath) prior to patient/resident transport to [MEDICAL TREATMENT]. Post [MEDICAL TREATMENT]: Verify Physician Orders. Upon return from [MEDICAL TREATMENT], take and record patient/resident blood pressure, pulse and observations of the dressing at the access site. Palpate for evidence off thrill and auscultate bruit before and after [MEDICAL TREATMENT], documenting both as appropriate and notifying physician if they are absent . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] for Resident #1 recorded the resident had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #1 had impairment on both upper extremities. The MDS recorded the resident received [MEDICAL TREATMENT] in the last 14 days, before admission, and since admission to the facility. Resident #1's clinical record lacked a baseline care plan for [MEDICAL TREATMENT] or for monitoring his/her fistula. The [MEDICAL TREATMENT] care plan developed on 1/15/20 (12 days after admission) included the interventions: Monitor for thrill and bruit every shift left upper arm Monitor left upper arm and report to MD (Medical Doctor) signs of localized infection (localized… | 2020-09-01 |
| 4011 | 4011 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 725 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide sufficient nursing staff to provide care and services for two (2) of twenty (20) sampled residents (Resident #26 and Residents #34). Seven (7) residents in a group interview reported incidents of lack of care due to insufficient staff available to answer call lights. Resident #26 received bed baths only and did not receive a shower, as requested, only four (4) times during a six (6) month period. Resident #34 received bed baths only and did not receive a shower, as requested, for approximately two (2) months. The findings include: An interview was conducted on 1/14/20 at 10:00 AM with seven (7) members of the resident council. When questioned regarding staff response to call lights and the provision of care and services needed all the residents expressed having concerns with these issues. The residents went on to report call lights are not being responded to in a timely manner, reporting that sometimes at night it takes up to an hour for staff to respond. At times, the nurse will eventually enter the room, report there is no Certified Nursing Assistant (CNA) available on the hallway, and the nurse has to change us (referring to incontinence care). There are times when a CNA will enter the room in response to a call light, turn the light off, and state I'm not your CNA. The CNA will tell them they will report their request for service to the assigned CNA. However, no one ever comes back. The residents reported when their assigned CNA does answer the call light, they will turn the light off and tell the resident they are making rounds right now and cannot tend to their need until finish rounds. The residents are told they can't come out of sequence. The residents stated they observed staff sitting at the nursing station, sitting on the counter, as call lights were not being responded to. Some residents would ye… | 2020-09-01 |
| 4012 | 4012 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 804 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined the facility failed to ensure food was palatable by maintaining the temperature of the food at the point of delivery for one (1) of four (4) kitchenettes, affecting 66 residents. Observation of the test tray from the lunch meal on 1/13/2020 on the Killian hall, revealed point of service temperatures for hot foods were below 135 degrees Fahrenheit (F) which was not in accordance with facility policy. The findings include: Review of the facility Policy titled, Food Temperatures, revised date 3/24/16, revealed all foods served from the steam table must be held at or above 135 degrees and all potentially hazardous cold foods must be held at 41 degrees or less. Exempt hot foods include bacon, pancakes, waffles, toast, French toast, no temperature check is indicated. Continued review of the policy revealed food should not be heated/cooked on the steam table for it may foster bacterial growth and delete nutritive value and quality of food. Hot food should be heated using direct heat of the oven, stove, steamer, etc. Once heated above 135 degrees, hot food may be transferred to the heated steam table for serving. Food should be transferred to the steam table no more than 30 minutes prior to resident serving time. If the food item is not within acceptable range, it must be removed and reheated to 165 degrees for 15 seconds and food will be served at palatable temperatures. Continued policy review revealed ways to maintain temperature tips included deliver carts immediately to units when complete, do not portion out food ahead of time, make sure all equipment is in proper working condition, and stir hot foods from the middle to the outside to maintain an even temperature throughout the meal service. Review of the facility's policy titled, Meal Delivery, revealed all foods leaving the kitchenette is to be served to residents in their rooms covered, hot food items will be served with… | 2020-09-01 |
| 4013 | 4013 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 812 | F | 1 | 1 | YEP811 | > Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 01/13/20, during the tour of the dry food storage area, revealed food items had been opened and not labeled with the use by date. The findings include: Review of the facility's policy titled, Labeling, Dating and Storage, reviewed date 10/18/17, revealed all food and beverage items would be properly labeled with the name of the item, and a use by date. Foods would be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. Observation of the dry food storage area in the kitchen, on 1/13/2020 at 9:30 AM, revealed the following food items opened, wrapped in film with no opened and use by date: one (1) 36.8 ounce (oz) box of Quick 5-Minute Quaker Grits; one (1) 24 oz bag of French's Crispy Fried Onions; one (1) 16 oz bag of Domino Confectioner's Sugar; two (2) bags of White Cake Mix, one (1) 32 oz bag of Pie Filling Mix; one (1) 1.5 pound (lb.) bag Sysco Home Style Old Fashioned Biscuit Gravy Mix; and one (1) 16 oz bag of Frito Lay Corn Chips. Interview on 1/13/2020 at 9:55 AM with Dietary Cook #1, revealed that all food items should have a label on them with the received date, opened date, and use by date when they are stocked in the dry food storage area. He/she stated that it's important to dispose of the items by the use by date to prevent the residents from getting sick from old food. Interview on 1/13/2020 at 10:04 AM with the Dietary Manager, revealed that it's the responsibility of all staff to stock the food in the dry food storage area. Continued interview revealed that staff should print and place a label on the food item with the received, opened and use by date. Additionally, he/she stated that he/she ensures that all the food items are sealed, labeled and d… | 2020-09-01 |
| 4014 | 4014 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 880 | F | 1 | 1 | YEP811 | > Based on interview and review of facility policy it was determined the facility failed to implement protocol to ensure an ongoing Infection Prevention and Control Program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The findings included: Review of a policy entitled Infection Prevention and Control Program Overview (revised on 1/15/16, last reviewed on 4/20/17) revealed it was policy of the facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and partners. The policy specified it was the Administrator of the facility that was responsible for the Infection Control Program. Procedures established to implement the policy included: Patient/resident infection cases are monitored and documented by the Infection Preventionist (IP). The IP reviews cases of infections, including tracking and analysis of the findings and develops an action plan to resolve identified concerns. A report of resident infections is reported monthly to the Administrator and Director of Health Services (DHS) and quarterly to the Infection Control Committee. The IP completes the Infection Control Committee Quarterly Summary Form and submits to the Infection Control Committee. Partner (staff) infections are reported by the partner to the partner's supervisor, then to the IP. The IP completes the Partner's Infection Report Form and report is submitted: (1) Monthly to the Administrator, (2) Quarterly to the Infection Control Committee; (3) Quarterly to the Senior Nurse Consultant. Compliance with Infection Control Practices are monitored and documented by: (1) Staff Competency; (2) Observation of practices. The IP, DHS, and Department Managers review the compliance monitoring and initiate appropriate corrective measures, if indicated. Review of a second policy entitled Infection Prevention and Control Surveillance (Revised 11/21/17) re… | 2020-09-01 |
| 1129 | 1129 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 561 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that 2 of 19 sampled residents (Resident #5 and Resident #6) were allowed to make personal choices and engage in intimate behavior in the privacy of their room. Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet in the Electronic Medical Record (EMR) revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located under the Care Plan tab of the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #6's face sheet, located under the Profile tab of the EMR revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment with an ARD of 09/23/19, located under the MDS tab of the EHR, revealed a BI[CONDITION] score of 13, indicating he/she was cognitively intact. Further review of the MDS revealed no hallucinations, delusions, or behavioral concerns. Review of Resident #6's care plan, located under the Care Plan tab of his EMR, revealed a focus which read, I have an alteration in mood (as evidenced by) inappropriate sexual behavior, added 10/01/18. The interventions inclu… | 2020-09-01 |
| 1130 | 1130 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 656 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, policy review, and medical record review, it was determined the facility failed to ensure that the care plan was followed for 1 of 19 sampled residents (Resident #16). On [DATE] Certified Nurse Aide (CNA) #3 and CNA #4 transported Resident #16 back to his/her room. CNA #3 and CNA #4 stated although Resident #16 was a mechanical lift for transfer, they transferred Resident #16 back to bed without using a mechanical lift by supporting Resident #16's legs and back. Findings include: The Face Sheet, located in the Electronic Medical Record (EMR) stated Resident #16 was admitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. An The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR stated Resident #16 had significant cognitive impairment and had not been transferred out of bed. Review of the Nurse Aide's Information Sheet that was undated, located in the EMR stated Resident #16 was confused and required a mechanical lift with two persons for transfer. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 12:30 PM, he/she stated a mechanical lift was to be used for residents who were not able to weight bear. The ADON stated Resident #16 was not able to weight bear and a mechanical lift and two staff were to be used for any transfers. The ADON stated Resident #16 was rarely out of bed. The Safe Lifting and Handling of Residents policy, dated July 2019, stated that staff lifting of residents shall be eliminated when feasible. A lift assessment should be completed on admission, quarterly, and annually, or with significant change. The Nursing Lift Evaluation Form, dated 11/4/19, located in the EMR stated Resident #16 was non weight bearing and was a full lift transfer. During an interview with CNA #1 on [DATE] at 2:30 PM and with CNA #2 on [DATE] at 9:28 AM, they stated prior to [DATE], Resident #16 had not requested they transfer him/her out of bed. CN… | 2020-09-01 |
| 1131 | 1131 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 657 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and policy review it was determined the facility failed to revise care plan interventions for 1 of 19 sampled residents, (Resident #5). Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet, located under the Profile tab of his/her Electronic Medical Record (EMR) revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located in the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #5's Interdisciplinary Team (IDT) progress notes, located under the Prog Notes tab of the EMR, revealed Resident #5 was discovered engaging in a sexual activity with another resident on 10/14/19 at 7:41 PM. Further review of the IDT notes revealed the residents were separated, the police were called, and the residents were prohibited from visiting privately the rest of the evening. Review of Resident #5's clinical record revealed a Death in Facility Tracking Record which documented she passed away on [DATE], thus was unavailable for observation or interview during the survey. An interview with the Social Services Director (SSD) on 01/14/19 at 10:45 AM revealed he/she had been informed that it was Resident #5's right… | 2020-09-01 |
| 1452 | 1452 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 582 | B | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to issue Advance Beneficiary Notice of Noncoverage (ABN) for two of two residents (Residents #94 and #255) discharged from Medicare Part A with benefit days remaining. The findings include: 1. Resident #94 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on 09/27/19. Although the resident was to be discharged from Medicare Part A with benefits days remaining, he would continue to be a resident in the facility. The facility did not issue an ABN. A second NOMNC was issued for services ending on 01/17/20. The resident was to be discharged from Medicare Part A with benefits days remaining, but he would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility. 2. Resident #255 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on [DATE]. Although the resident was to be discharged from Medicare Part A with benefits days remaining, she would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired F… | 2020-09-01 |
| 1453 | 1453 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 686 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record review, the facility failed to provide the necessary treatment for [REDACTED].#51) reviewed for pressure ulcers. Specifically, the facility failed to ensure the dressings to a resident's pressure ulcers remained intact to promote healing. The findings include: Resident #51 was admitted with [DIAGNOSES REDACTED]. She was admitted with multiple pressure ulcers. A review of a Minimum Data Set, dated dated [DATE], indicated Resident #51's cognition was severely impaired. She required extensive to total assistance with her activities of daily living. A review of the Wound Management notes dated 0[DATE], indicated the resident had an unstageable pressure ulcer to the left buttocks, left heel, and sacrum, a Stage 2 pressure ulcer to the right lower ischium and a deep tissue injury to the right heel. A review of a nurse's progress note dated 0[DATE] at 4:46 PM, indicated a bone biopsy had been completed from the sacral pressure ulcer. The resident was diagnosed with [REDACTED]. A review of a wound consultant note dated [DATE] indicated, There continues to be a significant amount of drainage from her wounds. A review of the physician's orders [REDACTED]. gauze in the wound and cover with a dry dressing. Change daily. During wound care observation and interview on 01/12/20 at 4:30 PM, Registered Nurse (RN) #100 was observed performing wound care for Resident #51. RN #100 indicated the resident was on transmission-based precautions due to osteo[DIAGNOSES REDACTED] to the sacral wound. The resident was rolled to her right side for the wound care. There were no dressings observed on the sacral or left buttock wounds. RN #100 stated, and it was observed, that the sacral wound was open to the bone. He stated the wound to the left buttocks was almost down to the bone as well. The resident had a disposable blue absorbent pad underneath her and it was observed with a large amount of wound exudate (drainage). The r… | 2020-09-01 |
| 1454 | 1454 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 688 | E | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, it was determined the facility failed to provide restorative range of motion services for one (#16) of three sampled residents reviewed on restorative services. The facility also failed to assess and provide services to one (#50) of three sampled residents who had limited use of her hands and could not open them without assistance. The findings include: 1. Resident #16 had [DIAGNOSES REDACTED]. A care plan, dated 10/04/19, documented, Problem.Resident requires training and skill practice in walking. Goal.Resident will walk in corridor 250 feet with rolling walker, supervision, and wheelchair follow. Interventions. Place resident in restorative nursing program: Patient requires stand by assist and wheelchair follow plus rolling walker for walking. Patient is easily fatigued w/minimal exertion and require seated rest periods .Discipline .Restorative Nursing Frequency .Once A Day. A quarterly Minimum Data Set (MDS) assessment, dated 10/23/19, documented the resident's cognition was intact. The resident required one-person limited assistance with transfers and did not ambulate in her room or in the hallway. The assessment further documented the resident did not have a restorative program. A review of the restorative nursing documentation revealed the last time the resident had been walked and provided restorative services was on [DATE]. The resident was not observed to be ambulated in the hallway at any time during the survey. On 01/11/20 at 10:22 AM, the resident stated there was not enough staff working to make sure she was walked at least three times a week to maintain her strength. She stated she was afraid she was going to get weaker if they did not continue to walk her. On 01/11/20 from 2:00 PM through 5:30 PM the resident was observed in bed. No staff was observed walking with her in the common area. On 01/12/20 at 4:06 PM the resident was observed transferring herself out of bed to the… | 2020-09-01 |
| 1455 | 1455 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 725 | F | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to ensure staffing was sufficient to meet the needs of residents. The census was 102. The facility failed to provide enough staff to meet the needs of residents who required restorative range of motion services for one (Resident #16) of three sampled residents reviewed on restorative services. The findings include: 1. A facility policy titled, State Minimum Staffing for Healthcare Centers, documented: .Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care . Resident council meeting notes, dated 10/09/19, documented, .Nursing .The Council would like The Nurse and Certified Nurse Aide (CNA) that is assigned to the dining room duty to show up on time . Resident council meeting notes, dated 12/11/19, documented, .Nursing .The Council is displeased with the service in the main dining room. Often Nursing staff is not on time for dining room duty .The Council is concerned with nursing and CNA shortage. They said often their lights are on 25 minutes to 30 minutes. They are also concerned of the present staffing being overworked and doing double duties . Resident #82 had [DIAGNOSES REDACTED]. She required extensive or total assistance from staff members with all activities of daily living. On 01/11/20 at 1:08 PM, two family members of Resident #82 were asked if there were enough staff to care for residents' needs. They stated, because of the staff shortage, at times care was delayed for their family member. They stated residents were not assisted up and made ready for the day timely. They also expressed concern about the ability of the staff to offer supervision for their family member because of the staff shortage. Resident #68 had [DIAGNOSES REDACTED]. She required extensive or total assistance from staff members with all activities of daily living. On 01/11/20 at 1:50 PM, a family member of R… | 2020-09-01 |
| 1456 | 1456 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 756 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that any irregularities in medication orders were identified by the pharmacist during monthly reviews. This irregularity should then be addressed by the attending physician/nurse practitioner and the Director of Nursing Services (DNS). This failed practice affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility 05/16/17 with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders [REDACTED]. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN) #100. The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. An interview was conducted with the Consultant Pharmacist, (PharmD #115), on 01/13/20 at 4:28 PM concerning the order for [MEDICATION NAME] written for Resident #35 on 11/13/19. PharmD #115 was asked if the way this order for a psychoactive medication was written was okay. She stated, I must hav… | 2020-09-01 |
| 1457 | 1457 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 758 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that physician's orders for a psychoactive medication ([MEDICATION NAME], an antianxiety medication) was written with a frequency for administration and a stop-date for the prescription, not to exceed 14-days. This affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders observed was for [MEDICATION NAME] (an anti-anxiety medication), [MEDICATION NAME] - Schedule IV solution; 2 mg/mL (milligrams/milliliter; amt (amount): 1 mg; injection. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN #100). The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. | 2020-09-01 |
| 1458 | 1458 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 880 | E | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, record review and facility policy review, the facility failed to perform glove changes and hand hygiene appropriately during wound care observation for one of three residents (#51) reviewed for pressure ulcers. The facility failed to perform wound care in a manner as to prevent potential cross contamination between non-infected and infected wounds for one of three residents (#51). The facility failed to utilize dedicated wound care supplies for one of one resident (#51) on transmission-based precautions. The findings include: Resident #51 was admitted with [DIAGNOSES REDACTED]. She was admitted with multiple pressure ulcers. A review of a Minimum Data Set, dated dated [DATE], indicated Resident #51's cognition was severely impaired. She required extensive to total assistance with her activities of daily living. A review of the Wound Management notes dated 0[DATE], indicated the resident had an unstageable pressure ulcer to the left buttocks, left heel, and sacrum, a Stage 2 pressure ulcer to the right lower ischium and a deep tissue injury to the right heel. A review of a nurse's progress note dated 0[DATE] at 4:46 PM, indicated a bone biopsy had been completed from the sacral pressure ulcer. The resident was diagnosed with [REDACTED]. Review of a wound consultant note dated [DATE], indicated, There continues to be a significant amount of drainage from her wounds. 1. During wound care observation and interview on 01/12/20 at 4:30 PM, Registered Nurse (RN) #100 was observed performing wound care for Resident #51. RN #100 indicated the resident was on transmission-based precautions due to osteo[DIAGNOSES REDACTED] in the sacral wound. The nurse put on a disposable gown and gloves before entering the room. The resident was rolled to her right side to perform wound care and RN #100 noted she had a small bowel movement. He began by providing incontinent care. He then changed one glove only, to his right hand. H… | 2020-09-01 |
| 1459 | 1459 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 925 | E | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to maintain an effective pest control program. This failed practice was observed in the kitchen and one unit (300 Unit) out of three units in the facility where both live and dead roaches were observed. The findings include: 1. On 01/11/20 at 1:30 PM, a family interview was being done in room [ROOM NUMBER] for Resident #[AGE]. The family member pointed out two dead roaches (appeared to be German roaches) in the vent of the air conditioner. The family member stated they had been there for weeks. There was also a large roach (possibly a [MEDICATION NAME] bug) lying on it's back in the corner of the room. This roach would occasionally move its legs showing that it was not dead. During the interview, a large live roach was observed climbing up the wall in the corner of the room near the resident's bed. The family member stated that she had also seen one of the large roaches in the hall approximately two weeks before that staff killed when she pointed it out to them. An interview was done on 01/12/20 at 2:20 PM with the Maintenance Supervisor ([CONDITION] #12) about the roaches that had been observed. He stated that pest control had sprayed the building on [DATE]. On 01/13/20 at 1:06 PM, [CONDITION] #12 stated that pest control had come back on 01/12/20 to spray again because of the roach sightings and was coming back that day (01/13/20) to follow up. He further stated that last year there had been a problem with roaches in the dish room of the kitchen and work had been done to repair the cracks in the floor where the roaches were observed entering the kitchen. He stated he was not aware that there were roaches being seen in the resident areas. 2. A review of the pest control records, dated 08/26/19, [DATE] and [DATE], documented, structural concerns.location kitchen area.interior.findings.floor tiles or baseboards loose/missing.action needed please repair to eliminate potential pest harbor… | 2020-09-01 |
| 952 | 952 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 623 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to give the resident and the resident representative in writing a notice of transfer in a language understood for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence of notice of transfer given to resident and resident representative. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident or the resident representative received a written notice of transfer. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he confirmed the transfer forms were not issued to the resident or the resident representative. | 2020-09-01 |
| 953 | 953 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 625 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to issue a bed hold notice to the resident representative upon discharge for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence a bed hold notice was issued. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident representative received a bed hold notice. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he stated a bed hold notice was not issued due to the resident being private pay. Review of the facility bed detail revealed all [AGE] beds were certified. | 2020-09-01 |
| 954 | 954 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 658 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on observations, record reviews and interviews the facility failed to assure that care and services were provided according to accepted standards of clinical practice for 1 of 5 residents reviewed for unnecessary medications. Resident #12 had two different physician orders [REDACTED]. An interview with the Director of Nursing (DON) revealed that the nursing staff providing care to Resident #12 failed to realize there were two different orders in place for finger stick blood sugar testing resulting in additional finger sticks. An interview with Licenses Practical Nurse (LPN) #3 revealed that s/he was aware that the orders were confusing but failed to report this to the DON. The findings included: Resident #12 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/08/20, at approximately 3:47 PM, a random medical record observation revealed that Resident #12 had two different physician orders [REDACTED]. On 1/8/20 at approximately 4:04 PM, LPN #3 stated that the orders were confusing and that he/she had been intending to report this to the DON (Director of Nursing) but had not done so. On 1/8/20 at approximately 4:37 PM, the Surveyor made the DON aware of the finger stick blood sugar testing concerns related to Resident #12. On 1/8/10 at approximately 5:20 PM, a review of physician's orders [REDACTED]. The first was an opened ended physician order [REDACTED]. Blood Sugar is less than [AGE], Call MD. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, Give 6 Units. If Blood Sugar is 301 to 350, Give 8 Units. If blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Three times a Day; 07:30 AM, 11:30 PM, 05:30 PM. After reviewing Resident #12's medical record it revealed that Resident #12 was being tested ,[DATE] times daily for blood sugar levels. On 1/8/20 at approximately 5:40 PM, the DON stat… | 2020-09-01 |
| 955 | 955 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 732 | E | 1 | 1 | S0WQ11 | > Amended February 11, 2020 Based on record review and interview, the facility failed to post accurate daily staffing postings for 31 of 31 days reviewed. Postings observed with incomplete census and/or staff and inaccurate total number of hours worked. The findings included: Review of the facility postings on [DATE] at 11:00 revealed the following: 12/1-31/ 2019-all with inaccurate total of number of hours worked; 12/1, 3, 6, 7, 9, 15, 17, 19, 20, 22, 25, 27, 28, 29, 30, 31/2019- census not documented each shift; 12/1, 3, 6, 19, 20, 22/ 2019 licensed and non- licensed staff incomplete ; 12/1, 9, 22/ 2019-shift supervisor not documented. During an interview with the Director of Nursing on [DATE] at 8:15 AM, s/he confirmed the postings were incomplete and the total number of hours worked had not been calculated. S/he stated during the week the Unit Managers were responsible for ensuring correct information was documented on the postings and the week-end supervisors were responsible to place the correct information on the posting form on the week-ends. | 2020-09-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );