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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1615 | 1615 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 550 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policies and procedures the facility failed to ensure that:1) Staff knocked on doors prior to entering resident rooms and asked permission to enter Resident #49's room, 2) Staff asked permission of residents prior to placing clothing protectors on during dining, 3) Resident #216 was left unclothed and exposed in the shower room, 4) Resident #16 and #58 were transferred from wheelchair to shower chair in the hallway in front of residents and visitors, 5) The privacy curtain was pulled between Resident #17, who was NPO (Nothing by mouth) and receiving enteral feeding and Resident #63 who was eating in 2 of 2 dining observations and random observations of resident care. The findings included: On 02/06/18 at 12:19 PM observed in the hallway, Resident #16 and Resident #58 being transferred from the wheelchair they were seated in to a shower chair with toilet seat. The residents were then pushed on to a platform scale. The residents were then transferred from the shower toilet seat chair to their wheelchair. On 02/06/18 at approximately 12:30 PM during an interview with Certified Nurse Assistant #3, he/she said that we weigh people this way, we use the shower chair so that when we subtract the weight it is always the same. During an interview on 02/10/18 at 08:25 AM with DON , he /she said residents should not be weighed in the hallway. The Facility form titled, Ridgeland Nursing Center, Resident Rights states, (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The Facility form titled: Weighing Resident, Rev. 10/2017 states, Pre weighed shower chairs are used for residents unable to stand. During an observation on 02/09/18 at 01:29 PM: Re… | 2020-09-01 |
| 1616 | 1616 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 568 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Policy On Protection Of Resident Funds, the facility failed to ensure Resident # 18 and #22 received a quarterly statement of personal funds for 2 of 3 reviewed for Personal Funds. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED].#18 has a BIMS (Brief Interview of Mental Status) of 11 out of 15 on 11/29/2017. During an interview on 2/6/2018 at approximately 11:43 AM with Resident #18 he/she stated that he/she did not receive a quarterly statement of personal funds. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Resident #22 has a BIMS of 11 out of 15 on 12/1/2017. During an interview on 2/6/2018 at approximately 2:34 PM with Resident 22, he/she verbalized that he/she did not receive a quarterly statement of personal funds. During an interview on 2/9/2018 at approximately 1:45 PM with the Administrator and the Financial Officer, confirmed that residents do not receive quarterly statements. The Administrator went on to say that none of the residents receive quarterly statements that all of them go directly to the responsible parties. Review on 2/9/2018 at approximately 3:00 PM of the facility policy titled, Policy On Protection Of Resident Funds, states under number 1, The facility shall furnish the resident with a written receipt for all expenditures and deposits regarding any of the resident's funds deposited with the facility. Number 3 states, The resident shall have reasonable access, upon request, to the above record and shall receive an itemized quarterly statement of his/her account. | 2020-09-01 |
| 1617 | 1617 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 625 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure Resident #53 and Resident #53's personal representative received written information before transfer of the bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility for 1 of 2 residents reviewed for hospitalization s. The findings included: The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Review on 2/10/2018 at approximately 7:45 PM of the medical record for Resident #53 revealed no documentation to ensure Resident #53 and Resident 53's personal representative received written information before transfer to the hospital of the bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility. During an interview on 2/10/2018 at approximately 8:07 PM with the Social Service Director brought in a copy of a transfer report for the hospital staff and a list of documents sent with Resident #53 to the hospital, but no documentation that was presented to the resident and the personal representative in writing of the transfer nor the bed-hold policy in which the resident is permitted to return and resume residence in the nursing facility. | 2020-09-01 |
| 1618 | 1618 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 641 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure the MDS (Minimum Data Set) assessment Significant Change in status for Resident #56 dated 1/4/2018 was coded accurately related to dental and eating capabilities for 1 of 1 resident reviewed for Dental and for 1 of 4 residents reviewed for Nutrition. The facility further failed to ensure a MDS Quarterly assessment dated [DATE] for Resident #51 was coded accurately related to Activities of Daily Living. The findings included: The facility admitted Resident #56 with [DIAGNOSES REDACTED]. An observation on 2/6/2018 at approximately 12:46 PM revealed Resident #56 in room, feeding self a mechanical soft lunch. A second observation on 2/8/2018 at approximately 1:15 PM revealed Resident #56 on the sun porch with other residents feeding self a mechanical soft lunch. Review on 2/10/2018 at approximately 1:40 PM of the physician progress notes [REDACTED]. Review on 2/10/2018 at approximately 2:40 PM of the MDS Significant Change assessment dated [DATE] revealed under Section G, Functional Status, H. Eating as Resident #56 requires extensive assistance with eating and with the support of 1 person to assist. Resident #56 is able to feed his/her self. Further review on 2/10/2018 at approximately 2:40 PM of the MDS Significant Change assessment dated [DATE] Section L, Oral/Dental Status was coded incorrectly as Resident #56 has broken, missing teeth and mouth pain. Section L was coded as. None of the above were present. During an interview on 2/10/2018 at approximately 4:00 PM with the Social Service Director, answering for the MDS/Care Plan Coordinator confirmed that the MDS Significant Change assessment dated [DATE] was coded incorrectly for Resident #56 related to eating and his/her oral/dental status. | 2020-09-01 |
| 1619 | 1619 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 657 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to have all required disciplines participate in the care plan process for 9 of 28 residents reviewed.(Resident #14, 58, 56, 27, 34, 62, 49, 41, and 20) The care plan was not updated to reflect the type of restraint used for Resident #20(1 of 3 reviewed for restraints) and the care plan was not updated in the areas of dental care and weight loss for Resident #56.(1 of 1 reviewed for dental and 1 of 4 reviewed for nutrition) Resident #58 was not invited to his/her care plan(1 of 28 residents reviewed). The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Record review on 2/9/18 at 9:14 AM of the care plan participation revealed there was no documentation the Certified Nursing Assistant(CNA) participated in the care plan process on 3/24/17, 6/16/17, 9/15/17, and 12/1/17. There was no documentation the Certified Dietary Manager(CDM) participated on 3/24/17 and 6/16/17. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/9/18 of the care plan participation revealed there was no documentation the CNA participated in the care plan process on 3/31/17, 6/23/17, 9/22/17, and 12/15/17. There was no documentation the CDM participated in the care plan process on 3/31/17 and 9/22/17. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Record review on 2/9/18 of the care plan participation revealed there was no documentation the CNA participated in the 12/22/17 care plan process and there was no documentation the CDM participated in the 5/5/17 care plan process. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 2/10/18 at 9:06 AM of the care plan participation revealed there was no documentation the CNA participated in the 4/21/17, 7/21/17, 8/22/17, 10/13/17, and 1/5/18 care plan process and there was no documentation the CDM participated in the 8/22/17 care plan process. The facility adm… | 2020-09-01 |
| 1620 | 1620 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 684 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the care provided by the Hospice Health Aide for Resident #34 was signed off as complete by a Registered Nurse after the care was performed and not before for 1 of 1 resident reviewed for Hospice Care and Services. The findings included: The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Review on 2/8/2018 at approximately 12:20 PM of the medical record for Resident #34 revealed the Hospice Health Aide visiting Resident #34 and performing Activities of Daily Living 3 times weekly. Further review of the Hospice Health Aide forms revealed a Registered Nurse had signed off the care before it was completed on 2/9/18, and 5 blank sheets where the Registered Nurse had signed off on the care which had not been completed. During an interview on 2/9/2018 at approximately 11:15 AM with the Director of Nursing, he/she stated, I would expect the Hospice Nurse to sign after the Hospice Health Aide has completed the care, due to any changes the resident may have had. | 2020-09-01 |
| 1621 | 1621 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 692 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide services to maintain acceptable parameters of nutritional status for Resident #20 and #56 . Resident #20 and #56 with documented weight loss with no additional interventions. (2 of 4 reviewed for nutrition) The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Record review on 2/9/18 at 9:14 AM revealed the resident's ordered diet was Reduced Concentrated Sweets, No Added Salt Mechanical Soft with Ground Meat diet. Review of resident weights revealed a 1/4/18 weight of 112 pounds and on 2/6/18 weight of 102 pounds with no documentation of re-weigh. This surveyor asked for a re-weigh on 2/10/18 which resulted in a weight of 100.4 pounds. Review of the (MONTH) (YEAR) Registered Dietician recommendations stated to continue current nutrition plan of care. During an interview with the Director of Nursing on 2/10/18, s/he stated a re-weigh had been done but there was no documentation of the weight. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 2/7/2018 at approximately 3:37 PM of the medical record for Resident #56 revealed progress notes dated 7/19/2017 revealed a weight of 136 pounds. The weight on 1/10/2018 is documented as 117 pounds. The weight loss is a 19 pound weight loss. No documentation could be found in Resident #56's medical record to improve weight loss or to prevent further weight loss for Resident #56. During an interview on 2/10/2018 at approximately 10:45 AM with the DON (Director of Nursing) he/she was not able to find interventions to address the 19 pound weight loss for Resident #56 in the medical record. Review on 2/10/2018 at approximately 11:40 AM of the facility policy titled, Weight Assessment and Intervention, states under Policy: The nursing staff and the Dietitian will cooperate to prevent, monitor and intervene for undesirable weight loss. Number nine states, Interventions for undes… | 2020-09-01 |
| 1622 | 1622 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 698 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review and review of facility policy and procedure the facility failed to ensure coordination of care between the facility and the [MEDICAL TREATMENT] center for Resident #35 for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The findings included: Resident #35 was admitted with [DIAGNOSES REDACTED]. During a review of the medical record on 02/08/2018 at approximately 9:30 AM , the form titled, Ridgeland Nursing Center, Inc. Order Summary Report, the Physician order [REDACTED]. An observation, during the review of the [MEDICAL TREATMENT] Communication Book and the [MEDICAL TREATMENT] Center Communication Reports for Resident #35, revealed from the dates 1/2/2018 to 02/06/18, the following dates had no reports for [MEDICAL TREATMENT] treatments: 1/4/2018, 1/9/2018, 1/11/2018, 1/13/2018, and 2/1/2018 and 2/6/2018. The form titled, Ridgeland Nursing Center, 1516 Grays Highway, Ridgeland SC ., states: Attention [MEDICAL TREATMENT] Center: Please provide documentation of today's [MEDICAL TREATMENT] treatment, to include before and after weights, any lab work out of range, new orders, dietary information or any other pertinent information related to the care of the patient. Thank you for your cooperation in the continuity of care of our residents The form is the [MEDICAL TREATMENT] Center Communication Report, and was verified on 02/08/18 at approximately 4:40 PM by the ADON (Assistant Director of Nursing). On 02/08/18 at 4:30 PM during an interview with the ADON regarding the missing [MEDICAL TREATMENT] Communication Reports. He/she verified that no [MEDICAL TREATMENT] Center Communication Reports were in the [MEDICAL TREATMENT] Communication book for the dates:1/4/2018, 1/9/2018, 1/11/2018, 1/13/2018, and 2/1/2018 and 2/6/2018 . The ADON said that the [MEDICAL TREATMENT] Center Communication Reports are sent with the resident when he/she goes to [MEDICAL TREATMENT] and when the resident returns from [… | 2020-09-01 |
| 1623 | 1623 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 730 | E | 0 | 1 | C32011 | Based on record review and interview, the facility failed to ensure each CNA (Certified Nursing Assistant) employed by the facility received the required no less than 12 hours of in-service education based on their individual performance reviews and is calculated by their employment date with the facility during review of Sufficient and Competent Nurse Staffing. The findings included: Review on 2/10/2018 at approximately 1:45 PM of the facility's CNA annual 12 hour in-service training based on performance reviews revealed less than the required 12 hours of training from the date of hire for CNAs. During an interview on 2/10/18 at approximately 1:50 PM the Administrator stated, each CNA employed by this facility has not received the required 12 hours of in-service training from the date of hire. | 2020-09-01 |
| 1624 | 1624 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 755 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and manufacturer labeling, the pharmacy failed to assure that expired medications were removed from the emergency box in 1 of 2 medication rooms (emergency box kept in this medication room for all residents in the building) and that medications were properly labeled relevant to manufacturer's expiration date requirement in 1 of 2 medication rooms. The findings include: On 2/06/18 at approximately 08:46 AM inspection of the B Wing Medication Room Emergency Box revealed the following: Drawer 4 contained: -2 bottles of SPS (sodium [MEDICATION NAME]) Suspension 15 G (grams)/ 60 ml (milliliter), CMP Pharma Lot 3, expiration (MONTH) 18 -6 unit dose packaged tablets of [MEDICATION NAME] 0.8 mg (milligram) Lot 017-4TY, expiration 1/24/18 -6 unit dose packaged tablets of Donepezil 5 mg Lot BDF502A, expiration 1/31/18 -8 unit dose packaged tablets of [MEDICATION NAME] 5 mg Lot 017-57Y expiration 1/31/18 Drawer 1 contained: -1 unit dose packaged tablet of [MEDICATION NAME] 10 mEq (milliequivalent) ER (extended release) Lot 8066-70, expiration 1/31/18 -8 unit dose packaged tablets of [MEDICATION NAME] 20 mg Lot 4B, expiration (MONTH) (YEAR) On 2/6/18 at approximately 8:53 AM inspection of the medication room refrigerator revealed the following: -One reconstituted and opened bottle of [MEDICATION NAME] and Clavulanic Acid Suspension 250 mg /62.5 mg per 5 ml , dispensed 2/1/18 belonging to Resident 166. This bottle had not been dated as to expiration date and the manufacturer's label stated to discard 10 days after opening. | 2020-09-01 |
| 1625 | 1625 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 757 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy titled [MEDICAL CONDITION] Medications, the facility failed to document non-pharmacological interventions prior to administering an anti-anxiety medication for Res #27(1 of 6 reviewed for Unnecessary Medications). The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/9/18 at approximately 2:45 PM revealed a physician's order for [MEDICATION NAME] .25 milligrams(mgs) by mouth as needed for anxiety state. Review of the Medication Administration Records(MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #27 received [MEDICATION NAME] .25 mgs on 11/10/17, 11/14/17, 11/15/17, 11/18/17 x 2, 11/19/17, 11/20/17, 11/22/17, 11/28/17, 11/29/17, 11/30/17, 12/1/17, 12/7/17, 12/16/17, 12/17/17, 12/22/17 and 12/25/17. Further review of the medical record revealed there was no documentation to indicate a non-pharmacological intervention was attempted prior to the administration of the [MEDICATION NAME]. After reviewing the medical record on 2/10/18, the Director of Nursing confirmed if interventions were attempted, they were not documented. Review of the facility policy titled [MEDICAL CONDITION] Medications revealed the policy did not address attempting non-pharmacological interventions prior to the administration of the as needed medication. | 2020-09-01 |
| 1626 | 1626 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 759 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interview and Facts and Comparisons the facility failed to ensure that it was free of a medication error rate of 5 % (percent) or greater. The medication error rate was 14.3 % based on 4 of 28 opportunities for error. (Cross Refer F760) The findings include: ERROR # 1: On 2/6/18 at approximately 8:23 AM, during medication pass for Resident 167, LPN (Licensed Practical Nurse) # 1 administered 10 ml (milliliters) of [MEDICATION NAME] ([MEDICATION NAME] 200 mg (milligram) and [MEDICATION NAME] 30 mg per 10 ml). Reconciliation of medication pass for Resident 167 on 2/6/18 at approximately 9:25 AM revealed zero orders for [MEDICATION NAME] 10 ml in the February, (YEAR) physicians orders. ERROR # 2: Further review of the February, (YEAR) physician orders [REDACTED].# 1 during the medication pass observation on 2/6/18 at approximately 8:23 AM. ERROR # 3: On 2/6/18 at approximately 8:23 AM, during medication pass for Resident 167, LPN # 1 administered one crushed tablet of Senna (sennosides) 8.6 mg in vanilla pudding to Resident 167. Reconciliation of medication pass for Resident 167 on 2/16/18 at approximately 9:30 AM revealed an order for [REDACTED]. ERROR # 4: On 2/6/18 at approximately 8:23 AM, during medication pass for Resident 167, LPN # 1 mixed 17 Gm (gram) of PEG (polyethylene [MEDICATION NAME]) 3350 in approximately 4 oz. (ounces) of water and offered to Resident 167 to drink. Resident 167 drank approximately two ounces and refused to drink any more. Reconciliation of medication pass for Resident 167 on 12/16/18 at approximately 9:33 AM revealed an order for [REDACTED]. These findings were confirmed and verified by LPN # 1 on 2/6/18 at approximately 10:06 AM and with the Director of Nursing on 2/7/18 at approximately 9:59 AM | 2020-09-01 |
| 1627 | 1627 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 760 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to assure that it was free of significant medication errors. The medication error rate was 14.3 percent based on 4 errors out of 28 observations and 2 of these errors were significant medication errors. These errors occurred with Resident # 167 who had been readmitted by the Facility on 2/2/18 with [DIAGNOSES REDACTED]. (Cross Refer F759) The findings include: ERROR # 1: On 2/6/18 at approximately 8:23 AM, during medication pass for Resident 167, LPN (Licensed Practical Nurse) # 1 administered 10 ml (milliliters) of [MEDICATION NAME] ([MEDICATION NAME] 200 mg (milligram) and [MEDICATION NAME] 30 mg per 10 ml). Reconciliation of medication pass for Resident 167 on 2/6/18 at approximately 9:25 AM revealed zero orders for [MEDICATION NAME] 10 ml in the February, (YEAR) physicians orders. ERROR # 2: Further review of the February, (YEAR) physician orders [REDACTED].# 1 during the medication pass observation on 2/6/18 at approximately 8:23 AM. These findings were confirmed and verified by LPN # 1 on 2/6/18 at approximately 10:06 AM and with the Director of Nursing on 2/7/18 at approximately 9:59 AM. | 2020-09-01 |
| 1628 | 1628 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 812 | E | 0 | 1 | C32011 | Based on observation, interview and review of the facility policy and procedures, the facility failed to ensure: 1)The Walk in Cooler is maintained clean and free from dust and mold and is free of unsealed hole in the ceiling, 2) Food packages stored in the refrigerate which have been opened are sealed, labeled and dated. 3)The equipment used to prepare the puree food for the residents is stored clean and dry 5) Microwave ovens located on the A and B unit nursing units for the reheating of resident food are maintained are free from soil, corrosion, and food debris in 1 of 1 kitchen and 2 of 2 Nourishment kitchens. The findings included: 1) During the initial tour of the kitchen, an observation was verified by the Certified Dietary Manager (CDM) on 02/06/18 at 7:57 AM that the walk-in refrigeration unit has a hole in the ceiling with dust and mold surrounding the hole. The CDM said that s/he was not aware of the hole in the ceiling or the dust and mold surrounding the hole. During an observation on 02/09/18 at 09:47 AM, the hole in the ceiling of the walk in refrigerator has been repaired. There is a patch over the hole. The CDM said that he/she called repair company and the maintenance staff repaired immediately when he/she told him/her about it. The form titled, Ridgeland Nursing Center, Food Storage, states: Policy: Food storage areas will be maintained in a clean, safe, and sanitary manner ., Procedure: 1. Food services, or other designated staff will maintain clean food storage areas at all times. 2) During the initial tour of the kitchen on 02/06/18 at 7:57 AM an observation was made of a case of turkey bacon and inside the case is a package of turkey bacon which has been opened and was not sealed, labeled or dated. This observation was verified by the CDM. The form titled, Ridgeland Nursing Center, Food Storage, states: Policy: Food storage areas will be maintained in a clean, safe, and sanitary manner ., Procedure: 6. Prepared food stored in the refrigerator until service shall be dated with an expiration … | 2020-09-01 |
| 1629 | 1629 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 814 | E | 0 | 1 | C32011 | Based on observation and interview the facility failed to ensure that the Grease Receptacle was stored on a non-porous surface in 1 of 1 Grease Receptacle stored outside. The findings included: During an observation on 02/09/18 at 12:18 PM, the Grease Receptacle is sitting directly on dirt/soil and grass is growing in the soil, underneath the dirt is a solid surface. This observation was verified by the CDM who stated that he/she was going to inform the Administrator. During an observation on 02/10/18 at approximately 2:00 PM, the Grease Receptacle is sitting directly on muddy dirt and soil, there is a solid surface underneath the dirt and mud. This observation was verified by the CDM who stated that the Administrator is aware and researching option to ensure the Grease Receptacle is stored on a solid, non-porous surface | 2020-09-01 |
| 1630 | 1630 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 842 | D | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Advance Directives, the facility failed to ensure each resident's medical record was complete and accurate. Resident #56's meal intake was not documented daily.(1 of 4 reviewed for nutrition) In addition, Resident #41's medical record contained conflicting information related to code status.(1 of 28 reviewed for accuracy of medical record) The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Record review on 2/8/18 at 11:12 AM revealed the resident's chart had an orange DNR(Do Not Resuscitate) sticker. Review of the Advance Directives revealed a DNR had been signed by his/her spouse with a note the resident made the choice and instructed his/her spouse to sign the paperwork. Review of the current physician orders revealed a DNR order and a Full Code order was written. On 2/10/18 at 3:44 PM, after reviewing the resident's record, the Director of Nursing confirmed both a DNR order and Full Code order was listed on the resident's current physician orders. Review of the facility policy titled Advance Directives revealed the following: 5. Pending resolution of such discrepancies, as in all other cases, the facility will continue to honor valid orders of the resident's treating physician However, where the discrepancy involves an order of the physician to withhold or discontinue life-sustaining care, the facility will continue to render care sufficient to maintain the resident's health and life until the physician is contacted to resolve the conflict. The facility will make every reasonable effort to contact the physician or his designated alternate immediately The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 2/7/2018 at approximately 3:37 PM of the medical record for Resident #56 revealed progress notes dated 7/19/2017 revealed a weight of 136 pounds. The weight on 1/10/2018 is documented as 117 pounds. The weight loss … | 2020-09-01 |
| 1631 | 1631 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 880 | D | 0 | 1 | C32011 | Based on observation, interview and review of the facility policy titled, Handling and Storage of Clean and Soiled Linen, the facility failed to ensure soiled linen was bagged at site of collection before placing it in bins in the soiled utility rooms on the A and B halls for 2 of 2 halls observed during soiled linen pick up. The findings included: An observation on 2/9/2018 at approximately 8:45 AM of the soiled laundry pick up on the A and B halls by a Laundry Worker revealed soiled linen unbagged and dropped into soiled linen bins in the soiled utility rooms. During an interview on 2/9/2018 at approximately 8:45 AM with the Laundry Worker confirmed the soiled linen was not bagged. The Laundry Worker stated, the soiled linen should have been put in bags in the resident rooms before bringing it to the soiled utility rooms and placing it in the bins. Review on 2/9/2018 at approximately 10:50 AM of the facility policy titled, Handling and Storage of Clean and Soiled Linen, states under Policy: All linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment for patients, health care workers, and visitors. Under Procedure: 1. Soiled or dirty linen is: (a) Bagged at site of collection and is transported to a specific area in a closed, soiled linen, bag. Minimal handling of soiled linen is advised. | 2020-09-01 |
| 1632 | 1632 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 908 | E | 0 | 1 | C32011 | Based on observations, interview and review of the facility policy titled, Laundry Services, the facility failed to ensure clothes dryers were free from an excessive amount of lint build up in 2 of 2 clothes dryers observed. The findings included: An observation on 2/9/2018 at approximately 8:40 AM of 2 of 2 clothes dryers revealed an excessive amount of lint build up on the wires and above lint baskets. During an interview on 2/9/2018 at approximately 8:40 AM with the Laundry Worker and the Maintenance Director confirmed the findings. The Maintenance Director stated, I thought the laundry personal were cleaning the lint from above the baskets and the wiring and they thought I was cleaning it. Review on 2/9/2018 at approximately 10:00 AM of the facility policy titled, Laundry Services, states under Purpose: To provide laundry services as needed to the residents in a clean and sanitary manner. The facility will provide the necessary equipment and supplies to properly maintain the efficient operation of the Laundry Department. All Federal, State and Local regulations will be followed. Under Responsibilities: The laundry area shall be kept clean and neat, free from debris, fire and chemical hazards. | 2020-09-01 |
| 1633 | 1633 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2019-02-22 | 561 | D | 0 | 1 | 3PCE11 | Based on observation and interview, the facility failed to serve residents in a manner that promoted choice and self-determination for one meal in 1 of 3 dining rooms. Facility staff failed to serve residents sequentially. The findings included: Observation of the lunch served on 2/19/19 at 12:55 PM to 12 residents on the A wing 100 unit revealed the residents were not served sequentially. The A wing had 2 tables. Table one had four residents waiting to eat. Table two had six residents waiting to eat. Two additional residents were sitting in wheelchairs and against the wall not seated at a table. Three staff members delivered the lunch trays non-sequentially to all the residents. The two residents in wheelchairs against the wall did not receive trays. Certified Nursing Assistant (CNA) #2 stayed in the area to assist the residents with eating. The other staff left. CNA #2 proceeded to get a tray off the cart and pulled one of the two residents from the wall to be fed. The other resident remained alone against the wall. When CNA #2 was asked on 2/19/19 at 1:09 PM if s/he was normally alone in the A hall, s/he stated that there were two residents that required assistance in the dining room and sometimes I get help, but it depends since there were two others that need assistance in their rooms. | 2020-09-01 |
| 1634 | 1634 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2019-02-22 | 656 | D | 0 | 1 | 3PCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy on Plan of Care Assessments, the facility failed to develop care plans for behaviors for 1 of 5 residents reviewed for unnecessary medication (Resident #45) and for dental services for 1 of 1 residents reviewed for dental care (Resident #13). The findings included: The facility admitted Resident #45 on 5/6/2015 with [DIAGNOSES REDACTED]. During the initial survey tour on 2/19/19 at approximately 10:00 AM observed Resident #45 sitting on a sofa in his/her room. The resident did not respond appropriately to greetings, screamed, and cried inappropriately at times without any tears. On 2/20/19 at 3:15 PM, observation revealed Resident #45 lying on his/her bed yelling loudly. The resident continued yelling off and on for a while as facility staff passed by his/her room without paying any attention to or addressing the resident's behavior. On 2/21/19 at approximately 10:00 AM, observation revealed the resident yelling again. The housekeeping staff who was providing services to the room across the hall said the resident's behavior (yelling/screaming) was usual for him/her. According to resident's Behavior Management Program Weekly Documentation Update (updated on 2/7/19) reviewed on 2/20/10 at 2:20 PM, the resident continued to have yelling episodes despite medication adjustment and attempts to redirect. There was no documentation in the resident's clinical chart to indicate the type of non-pharmacological behavior prevention interventions put in place other than to redirect. The resident's care plan reviewed on 2/20/19 at 3:15 PM revealed that the facility did not develop/implement a resident-centered care plan related to Resident #45's behavior of screaming/yelling and non-pharmacological behavior prevention interventions. During an interview with the Licensed Practical Nurse #1 on 2/20/19 at approximately 3:30 PM, s/he stated that Resident #45 yelled out aloud but… | 2020-09-01 |
| 1635 | 1635 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2019-02-22 | 791 | D | 0 | 1 | 3PCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to refer a resident with missing teeth and tooth decay to outside resources for dental care for 1 of 1 residents reviewed for dental care (Resident #13). The findings included: The facility admitted Resident #13 on 9/14/18 with [DIAGNOSES REDACTED]. During an observation on 2/19/19 at 12:46 PM, Resident #13 appeared to have missing teeth and tooth decay. During this visit as the resident smiled, observation revealed one tooth with decay around it and no teeth on either side of that one tooth. Progress notes reviewed on 2/22/19 at 8:59 AM revealed that Resident #13 had three oral assessments dated 10/30/18, 11/12/18, and 12/4/18 with no referral to social services to coordinate a dental exam/services despite the conclusion that the resident had a visible cavity, broken natural teeth, one tooth at the top with a cavity, and a few broken teeth at the bottom with carries. According to the oral assessments on 10/30/18 and 12/4/18, the resident would be seen by the in house dentist; however, there was no documentation in the chart to support that the resident received any dental services. The Minimum Data Set (MDS) assessment reviewed on 2/22/18 at 9:05 AM revealed that during the brief interview for mental status (BIMS) the resident scored 3, indicating severe cognitive impairment. During an interview with the social worker on 2/22/19 at approximately 9:35 AM, s/he confirmed that dental services were not provided for Resident #13. | 2020-09-01 |
| 1636 | 1636 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2019-02-22 | 812 | F | 0 | 1 | 3PCE11 | Based on observation, interview, and review of South [NAME]ina Regulation 61-25 - Retail Food Establishments, the facility failed to store food following standards for food service safety in 1 of 1 kitchens. The facility failed to store food off of the floor in the walk-in freezer. The findings included: During the initial kitchen tour on 2/19/19 at 10:35 AM, observation of the kitchen walk-in freezer revealed it was packed with boxes of food on the floor. When asked about storage of the boxes of food at this time, the dietary manager stated that s/he did not know that regulations of storing items 6 inches above the floor applied to the walk-in freezer. S/he also said that the facility was working on adding more shelves to get the food off the floor. South [NAME]ina Regulation 61-25 - Retail Food Establishments (June 27, 2014) states, food shall be protected from contamination by storing the food .(3) At least 15 cm (6 inches) above the floor. | 2020-09-01 |
| 1637 | 1637 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2019-02-22 | 908 | F | 0 | 1 | 3PCE11 | Based on observation and interview, the facility failed to maintain equipment in safe working condition. The ice-maker was malfunctioning in 1 of 2 units. The dishwasher was in need of repair or replacement to ensure it reached the correct temperature in 1 of 1 kitchens. The findings included: During a random observation on 2/20/19 at 4:40 PM, observation revealed a room on unit A with water accumulated on the floor. The ice-maker was unplugged ice-maker with the cord on the floor. The ice-maker was full of ice. During an interview with the dietary manager, s/he stated that s/he did not know why the ice-machine was unplugged with water around it and the cord on the floor. S/he stated that s/he was going to talk to maintenance immediately. During an interview with Certified Nursing Assistant #1, s/he stated that the staff in unit A unplugged the ice-machine because it would not stop making ice and it overflows out of the icebox even with the door down. During a dishwasher cycle observation on 2/22/19 at approximately 10:00 AM, the dietary manager had to re-start the dishwasher several times for it to reach the appropriate temperature (180 Fahrenheit or above). When asked about the dishwasher, s/he stated that the dishwasher was very old. S/he said that the repairman looked at it several times and suggested to re-start it if it did not reach its temperature. When asked how s/he made sure that staff would re-start the machine if it did not reach the required temperature, s/he stated that kitchen personnel was educated on this. The facility did not keep a log or other documentation to track how often this issue occurred. During an interview with the administrator on 2/22/19 at 10:15 AM, s/he acknowledged that the dishwasher had issues but indicated s/he was not aware of the problems with the ice-machine on unit [NAME] | 2020-09-01 |
| 1638 | 1638 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2017-07-05 | 223 | G | 1 | 0 | F6AE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interviews, the facility failed to ensure that each resident remained free from abuse. Certified Nursing Assistant (CNA) #1 physically abused Resident #1 when the resident attempted to leave the table on the facility sun porch. One of three residents reviewed for abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 6/20/17. Review of the facility's Five-Day Follow-Up Report dated 6/20/17 indicated video of the incident did substantiate the abuse allegation. On 6/19/17, the Social Services Director was alerted by an anonymous phone call to check the suggestion box. In the box was a letter stating that CNA #1 slapped a resident after the resident slapped him/her. The letter suggested the video should be watched and that the incident had been reported to the charge nurse. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 9. The Quarterly MDS coded the resident as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility. Resident #1 was coded as having other behaviors occurring 1-3 days during the assessment period. Review of the Nurses' Notes dated 6/16/17 revealed there was no documentation related to the incident on 6/16/17. A Nurses' Note dated 6/20/17 at 10:13 AM indicated a call was placed to the resident's responsible party with information regarding the resident's incident on Friday. Review of the letter left in the suggestion box indicated (CNA #1) hit (Resident #1) on 6/17/17 because s/he hit him/her. It's on the film on B wing. Nurse (Licensed Practical Nurse (LPN) #1) is aware and did not turn it in. (Resident #1) did hit him/her first. Check the film. Concerned employee There was no facility-obtained statement for LPN #1. In an interview with the surveyor on 7/5/17 at approximately… | 2020-09-01 |
| 1639 | 1639 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2017-07-05 | 225 | G | 1 | 0 | F6AE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported immediately. Resident #1 reported an allegation of physical abuse by Certified Nursing Assistant (CNA) #1 to Licensed Practical Nurse (LPN) #1 and CNA #2. The allegation was not reported to administration timely and CNA #1 continued to work at the facility after hitting a resident. One of three residents reviewed for abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 6/20/17. Review of the facility's Five-Day Follow-Up Report dated 6/20/17 indicated video of the incident did substantiate the abuse allegation. On 6/19/17, the Social Services Director was alerted by an anonymous phone call to check the suggestion box. In the box was a letter stating that CNA #1 slapped a resident after the resident slapped him/her. The letter suggested the video should be watched and that the incident had been reported to the charge nurse. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 9. The Quarterly MDS coded the resident as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility. Resident #1 was coded as having other behaviors occurring 1-3 days during the assessment period. Review of the Nurses' Notes dated 6/16/17 revealed there was no documentation related to the incident on 6/16/17. A Nurses' Note dated 6/20/17 at 10:13 AM indicated a call was placed to the resident's responsible party with information regarding the resident's incident on Friday. Review of the letter left in the suggestion box indicated (CNA #1) hit (Resident #1) on 6/17/17 because s/he hit him/her. It's on the film on B wing. Nurse (LPN #1) is aware and did not turn it in. (Resident #1) did hit him/her first. Check the film. Concer… | 2020-09-01 |
| 1640 | 1640 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-07-19 | 602 | G | 1 | 0 | BYB211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to prevent misappropriation of resident property for 1 of 3 residents sampled for Personal Funds. The findings included: The facility admitted Resident #1 on or about 12/27/2017 with [DIAGNOSES REDACTED]. July 17, 2018 record review revealed the facility reported that on 02/07/18 that a report was filed with the local Police Department by an elderly victim after information was received from his/her bank that a total of 9 checks, totaling $1700, had been presented against his/her account bearing fraudulent signatures between December 27, 2017 and January 20, 2018. A review of surveillance footage and banking records identified Certified Nursing Assistant (CNA) #1 as the person responsible. A police report obtained on 07/18/18 from the investigating police department revealed the department obtained a subpoena and received photos/video of CNA #1 at the drive-thru window on 01/16/18 and at the ATM on 01/27/18 of the Bank #2. Further review of the police report revealed the following statement from the investigating officer: On February 7, 2018, (this officer) met with (Resident Representative) in reference to forged checks cashed against Resident #1's bank account (Bank #1). (Resident Representative) helps care for his/her father who is ill and is currently at the Ridgeland Nursing Home. S/he provided copies of checks number 1799, 1800, 1801, 1802, 1820, 1821, 1822, 1823, 1824, s/he states that the checks were forged. S/he provided a written statement that the handwriting on the checks was not her/his or her/his father's. The checks were made out to CNA #1 who signed his/her name on the back of the checks. Two of the checks (1799, 1800) were cashed at Bank #1. S/he provided her/his SC DL and her/his thumb print for identification. Two of the checks (1801, 1802) were deposited at Bank #2 (CNA #1's bank). The remaining checks (1820, 1821, 1822, 1823, 1824) were endorsed and p… | 2020-09-01 |
| 1641 | 1641 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-07-19 | 607 | G | 1 | 0 | BYB211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to develop/implement abuse policies for 1 of 3 residents sampled for Personal Funds. The findings included: The facility admitted Resident #1 on or about 12/27/2017 with [DIAGNOSES REDACTED]. July 17, 2018 record review revealed the facility reported that on 02/07/18 that a report was filed with the local Police Department by an elderly victim after information was received from his/her bank that a total of 9 checks, totaling $1700, had been presented against his/her account bearing fraudulent signatures between December 27, 2017 and January 20, 2018. A review of surveillance footage and banking records identified Certified Nursing Assistant (CNA) #1 as the person responsible. A police report obtained on 07/18/18 from the investigating police department revealed the department obtained a subpoena and received photos/video of CNA #1 at the drive-thru window on 01/16/18 and at the ATM on 01/27/18 of the Bank #2. Further review of the police report revealed the following statement from the investigating officer: On February 7, 2018, (this officer) met with (Resident Representative) in reference to forged checks cashed against Resident #1's bank account (Bank #1). (Resident Representative) helps care for his/her father who is ill and is currently at the Ridgeland Nursing Home. S/he provided copies of checks number 1799, 1800, 1801, 1802, 1820, 1821, 1822, 1823, 1824, s/he states that the checks were forged. S/he provided a written statement that the handwriting on the checks was not her/his or her/his father's. The checks were made out to CNA #1 who signed his/her name on the back of the checks. Two of the checks (1799, 1800) were cashed at Bank #1. S/he provided her/his SC DL and her/his thumb print for identification. Two of the checks (1801, 1802) were deposited at Bank #2 (CNA #1's bank). The remaining checks (1820, 1821, 1822, 1823, 1824) were endorsed and per informatio… | 2020-09-01 |
| 1642 | 1642 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 159 | E | 0 | 1 | TQ9911 | Based on record review and interviews, the facility failed to assure that 3 of 3 residents sampled for personal funds had written authorizations for specific deductions from their accounts. The facility had general authorizations for Residents #40, #68, and #87 to manage their accounts, but failed to obtain authorizations for specific deductions. The findings included: Review of the accounting for the above-listed residents with the Administrator on 11-3-16 at approximately 3 PM revealed no authorizations for specific deductions from their funds: (1) Resident #40 had monies in the Personal Funds account managed by the facility. Review of the accounting period from 8-1-16 through 10-31-16 revealed deductions from the account for room and board charges without specific authorization to do so. (2) Resident #68 had monies in the Personal Funds account managed by the facility. Review of the accounting period from 8-1-16 through 10-31-16 revealed deductions from the account for hairdressing/barber charges without specific authorization to do so. (3) Resident #87 had monies in the Resident Trust account managed by the facility. Review of the accounting period from 8-1-16 through 10-31-16 revealed deductions from the account for room and board and hairdressing/barber charges without specific authorization to do so. The Administrator stated at the time of the review that s/he was unaware that the facility needed authorization for specific deductions from the personal funds accounts. | 2020-09-01 |
| 1643 | 1643 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 164 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy entitled Resident Rights, the facility failed to provide full visual privacy during personal care for one of three sampled residents reviewed for urinary incontinence. Staff toileted Resident #83 with the resident's room and bathroom doors open. The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. During observation of incontinent care at 9:58 AM on 11-2-16, Certified Nursing Assistant (CNA) #4 parked the resident's wheelchair in the open doorway to the resident's room and locked it in place. The CNA removed the soft waist restraint and ambulated the resident to the bathroom. S/he assisted the resident to pull down her/his pants, detach the disposable brief, and sit on the commode without closing the bathroom door or the door to the corridor. When the resident had finished toileting, the CNA closed the door to the hallway before wiping the perineum. While the resident was standing without her/his clothing in place, CNA #2 entered the room from the hall without knocking and closed it back. CNA #3 then opened the hall door without knocking with a shower chair in tow and said CNA coming in. This also occurred while the bathroom door was open and the resident standing without her/his clothing in place, in full view of both CNAs. CNA #4 stated the other two CNAs were on the shower team for that day. During an interview on 11-2-16 at 3:58 PM, the Director of Nurses stated that privacy should be afforded residents during toileting. The facility's policy entitled Resident Rights states: These rights ensure that each resident admitted to this facility: .9. Is treated with consideration, respect and full recognition of his dignity and individuality, including in treatment and in care for his personal needs. | 2020-09-01 |
| 1644 | 1644 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 221 | E | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that restraints were properly applied and applied per physician's orders for 2 of 2 sampled residents reviewed for physical restraints. Physician's Orders for restraint application were not followed for Residents #64 and #83. The findings included: The facility admitted Resident #64 with [DIAGNOSES REDACTED]. Record review on 11-3-16 at 1:30 PM revealed Physician's Orders for Soft waist belt with straps to kickspurs when OOB (out of bed) to wc (wheelchair) q (every) shift to deter unassisted transfers and gait. Review of the Care Plan at 2:58 PM on 11-3-16 revealed a focus area of fall risk with an intervention of restraint application: WC with soft waist belt with straps to kickspurs when OOB to wc q shift to deter unassisted transfers and gait. Multiple observations (on 10-31-16 at 2:25 PM, 2:58 PM, and 4:41 PM; on 11-1-16 at 11:18 AM; on 11-3-16 at 4:39 PM) revealed the resident in a wheelchair with a soft waist belt restraint tied to the wheelchair inappropriately. The straps were wrapped repeatedly around the arms and handles of the chair and knotted in the back. The straps were not secured to the kickspurs. During an interview on 11-3-16 at 3:46 PM, the Director of Nurses (DON) reviewed and verified the Physician's Order and Care Plan. When restraint placement was checked for Resident #64 with the DON, s/he confirmed that the restraint was improperly applied. The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Record review on 11-2-16 at 9:19 AM revealed a 9-16-16 Physician's Order for Resident up in w/c (wheelchair) (with) clip belt or gerichair (with) soft waist belt daily. Review of the Care Plan at 9:32 AM on 11-3-16 revealed a focus area including fall risk, history of falls, and history of removing/destroying alarms. Interventions included Restraint:OOB to WC with clip belt or to gerichair with soft waist belt to deter self transfers. Staff to release as … | 2020-09-01 |
| 1645 | 1645 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 241 | E | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide dignity during the dining experience on two of two units during all meals observed during the survey. Staff were observed standing while feeding residents on Unit [NAME] Residents were served food items in disposable bowls and served on trays. Seven to eight residents were observed eating from overbed tables on the Unit A porch instead of at dining tables. Residents were observed eating from overbed tables in the hallways near 2 of 2 nursing stations. The findings included: During the initial tour of the kitchen with the Certified Dietary Manager on 10-31-16, desserts were observed set up in styrofoam bowls in the refrigerator in preparation for the noon meal. During noon meal observation on 10-31-16, desserts were served in styrofoam bowls. During noon meal observation on 11-1-16, desserts and vegetables were served in styrofoam bowls. During meal observation in the Unit A sun porch on 11-2-16 at 8:30 AM, five residents were eating from disposable bowls. Oatmeal was served on plates, not in cereal bowls. On 11-2-16, the noon meal desserts were served in styrofoam bowls. During all meal observations, residents were served on trays at the tables in the main dining room and at the table in the Unit A sun porch. During an interview on 11-2-16 at 5 PM, the Certified Dietary Manager was unaware that dietary staff had been serving food items in disposable bowls. When asked if they were short on small bowls, s/he checked with the dietary staff who confirmed this. During meal observation on 11-2-16 at 8:30 AM, four residents were served at the one table in the room while 7 were eating off overbed tables in the Unit A porch. At 1:14 PM on 11-2-16, 3 of 4 residents seated at the table on the porch were different than earlier in the day. When asked about seating for the meal and how it was decided who sat at the dining table, Certified Nursing Assistant (CNA) #1 stated it was done on a… | 2020-09-01 |
| 1646 | 1646 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 253 | E | 0 | 1 | TQ9911 | Based on observations, an environmental round with Maintenance and Housekeeping Directors and review of the facility ' s policy entitled Housekeeping Department Operating Procedures: Daily Cleaning and Maintenance Services , the facility failed to provide necessary housekeeping and maintenance services to maintain sanitary, orderly, and comfortable interior. The facility had multiple areas of scuffed and damaged walls, broken outlet, and dust in residents ' bedrooms and bathrooms, tears in cushions, rusty paper towel holders, and wax build-up on floors. The findings included: Random observations were made in the facility during the survey process as follows: Room 123- Bathroom has rusted peeling commode frame, dark brown black buildup around base of commode-torn floorcovering in threshold build up corners and edges of baseboard. Bedroom corners and edges of room with buildup brown tiles, yellowing tiles around outer aspects of room-yellow build up and debris behind room door; Room 125-Bathroom peeling rusty soiled frame of stool riser; Room 126-Bathroom build up corners edges; Room 127- Bathroom has rusty peeling commode frame, dried spills on walls and brown stains around base of toilet; Room 128: Bedroom wall damage hear Heating Ventilating, Air Condition (HVAC) unit and 5-6 inch areas under wall mirror, corner of baseboard missing near closet. Loose baseboard at head of bed A-corners and edges with buildup all around room., Bathroom dried spills on wall from towel rack to baseboard, corners and edges of room with buildup, and dark brown around toilet base; Room 130: Bathroom has peeling rusty frame on stool riser-uncovered bedpan on floor. Bedroom buildup on baseboard and corners and edges of room -missing corner of baseboard near closet and door has dried food/spills. Bed A has footstool with brown dried spill on leg ~ 6 inches, wall damage behind head of bed-sheetrock dust and trash near bedside table-white grainy substance on floor by colorful drawers-stained over bed table; Room 135 - Bedroom plug cover mi… | 2020-09-01 |
| 1647 | 1647 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 272 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to accurately assess and stage a sacral pressure ulcer for Resident #22 for 1 of 2 residents reviewed with Pressure Ulcers. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. During an interview on 10/31/2016 at approximately 12:34 PM with Licensed Practical Nurse (LPN) #4 stated that Resident #22 has a chronic Stage IV pressure ulcer to his/her sacral area. An observation during wound care on 11/2/2016 at approximately 10:10 AM revealed a dime sized area with depth when packed with [MEDICATION NAME]. The wound bed is clean and the surrounding tissue is pink. Review on 11/2/2016 at approximately 12:51 PM of the medical record for Resident #22 revealed wound worksheets from 8/5/2014 through 10/24/2016 staging the pressure as a Stage II. The depth was recorded as small as 0.1 centimeters to 0.2 centimeters, until called to the attention of the staff, and at that time was measured and now is 0.3 centimeters in depth and is staged as a Stage III. Review on 11/2/2016 at approximately 2:32 PM of the MDS (Minimum Data Set) assessment dated [DATE] for Resident #22 revealed under Section M0300 a Stage II pressure ulcer. The definition of a Stage II in Section M0300 of the MDS reads, Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. A Stage III is defined as Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present that does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. A Stage IV pressure ulcer is defined on the MDS as, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar maybe present on some parts of the wound bed. Often includes undermining and tunneling, During an interview on 11/2/2016 at app… | 2020-09-01 |
| 1648 | 1648 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 279 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan to address provision of care and services to achieve as much normal urinary function as possible for one of three sampled residents reviewed for urinary incontinence. There was no care plan developed with measurable goals and individualized interventions to improve urinary incontinence for Resident #83 who had an assessed decline in continence. In addition, based on record review and interview, the facility failed to develop a care plan for aspiration risk for one of four sampled residents reviewed for nutrition. Resident #64's Care Plan did not include aspiration risk or the specific diet instructions per physician's orders [REDACTED]. The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review of the 6-24-2016 Admission Minimum Data Set (MDS) Assessment revealed that Resident #83 was coded as being occasionally incontinent (less than 7 episodes of incontinence). On the 8-15-16 5-Day and 9-5-2016 30-Day/Quarterly MDS Assessments, the resident was noted as frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). S/he required extensive assistance with transfers, toileting, and hygiene. The MDS noted no toileting plan had been attempted. Review of computerized assessments revealed no bladder assessment had been completed to identify predisposing and contributory factors to having urinary incontinence. The 6-24-16 initial bladder assessment was blank and the 9-16 assessment was noted as past due. Review of the Care Plan at 9:32 AM on 11-3-16 revealed incontinence identified as a concern only in relation to maintenance of skin integrity. Interventions to maintain intact skin integrity x 90 days included: Staff will assist with toilet as needed/requested and provide incontinence care management as needed. There was no Care Plan developed with individualized interventions to add… | 2020-09-01 |
| 1649 | 1649 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 280 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to evaluate and revise the care plan following falls to prevent recurrence for one of two sampled residents reviewed for accidents. Resident #83 had thirteen falls in a 3 month period with no changes in care planned interventions following 10 of the incidents to prevent recurrence. The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review of the 8-15-16 5-day and 9-5-16 30-Day Minimum Data Set (MDS) assessments revealed that the resident had a Brief Interview for Mental Status score of 1, indicating severe cognitive impairment. Signs of [MEDICAL CONDITION] included: inattention, disorganized thinking, trouble concentrating, short tempered, and easily annoyed. Extensive assistance was required for transfers and toileting. Record review on 11-2-16 at 9:19 AM revealed a 7-7-16 physician's orders [REDACTED]. Review of the Care Plan at 9:32 AM on 11-3-16 revealed a focus area including fall risk, history of falls, and history of removing/destroying alarms. Interventions included to ensure alarms are in place and functional. Review of Progress Notes and Incident Reports at 3:10 PM on 11-2-16 revealed that Resident #83 sustained eleven falls between 8-20-16 and 10-30-16, seven of which resulted in no care plan revisions to prevent recurrence. (1) On 8-23-16 at 4:31 PM, Resident was sitting at nurses station and slid from underneath the safety belt. Review of the report revealed that neither the sensor alarm or tab alarm was checked to indicate it was in place at the time of the fall. Review of the Care Plan revealed no changes in interventions to prevent recurrence. (2) On 9-2-16 at 7:16 PM, After administering medication to another resident, (the nurse) noticed resident on the floor in hallway in front of nurses station. The resident stated s/he unhook(ed) the belt. Review of the report revealed that neither the sensor alarm or tab alarm was checked to indic… | 2020-09-01 |
| 1650 | 1650 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 282 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to follow the care plans for 1 of 3 sampled residents reviewed for active daily living (ADLS). One of 3 sampled residents reviewed for dental, 1 of 3 sampled residents reviewed for accidents, 2 of 3 sampled residents reviewed for restraints. For Resident #58 the care plan not followed for oral care, Resident# 64 and 83 the care plan not followed for restraints, and Resident#83 the care plan not followed for accidents. In addition the care plan was not followed for 1 of 1 resident reviewed receiving [MEDICAL TREATMENT], Resident #93. The findings included: The facility admitted Resident#58 with [DIAGNOSES REDACTED]. During an interview with Resident # 58's Responsible Party (RP) on 11/1/16 at 3:20 PM revealed when asked Does (Resident #58) get the help he/she need getting dressed, toileting, or cleaning his/her teeth. The RP stated (Resident#58) teeth are horrible. During observation on 11/2/16 at 2:58 PM, Certified Nurse Assistant (CNA) #1 was asked, How long had s/he worked with (Resident#58?) CNA stated for a year. S/he also stated Don ' t know what has happen to the resident ' s teeth prior to beginning oral care. During the oral care, surveyor observed Resident # 58 teeth had yellow stains. Review of the Care Plan dated 11/1/16 on 11/3/16 at 11:38 AM revealed Mrs. Waters requires extensive to total assistance with her ADLS. Interventions included Staff will assist with/provide oral care as needed/request. Resident will visit dentist as needed/ordered. Review of the CNA daily documentation for (MONTH) (YEAR) through (MONTH) (YEAR) revealed Mouth Care in Morning and at Night. During the month of (MONTH) (YEAR) on 8/4/16, 8/6/16, 8/11-12/16, 8/18/16, 8/22/16, 8/26/16 either oral care was given once or not given at all. During the month of (MONTH) (YEAR) on 9/8-9/16, 9/16/16, 9/21/16, 9/23-24/16 oral care was only given once. During the month of (MONTH) (YEAR) on 10/5-… | 2020-09-01 |
| 1651 | 1651 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 309 | E | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, [MEDICAL TREATMENT] Residents Policy and Procedure, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for Resident # 93's thrill and brut not assessed and monitored for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. Resident #64's physician's orders not followed related to assistance with feeding and aspiration precautions and Resident #60's physician orders not followed for thickened liquids x 2 meals for 2 of 2 residents reviewed for Dental Services. The findings included: The facility admitted Resident #93 with diagnoses, including but not limited to, End Stage [MEDICAL CONDITION], Anxiety, and [MEDICAL CONDITION]. An interview on 11/3/2016 at approximately 9:48 AM with Licensed Practical Nurse (LPN) #4 confirmed that the [MEDICAL TREATMENT] access had not been monitored for a thrill and bruit to ensure proper functioning. No documentation could be found in the medical record to ensure the thrill and bruit has been checked every shift. Review on 11/3/2016 at approximately 11:22 AM of the facility policy titled, [MEDICAL TREATMENT] Residents Policy and Procedure, states under, Policy, Residents receiving [MEDICAL TREATMENT] must be monitored closely after receiving [MEDICAL TREATMENT] treatment. The following must be checked and assessed. Number 2 states, :If the resident has a graft for [MEDICAL TREATMENT], then, after [MEDICAL TREATMENT] and upon return to Ridgeland Nursing Center, the nurse will check for thrill and bruit, as she will daily thereafter. Notify [MEDICAL TREATMENT] Center of absence of thrill and bruit. Dressing will remain in place until AM following [MEDICAL TREATMENT]. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review at 12 PM on 11-2-16 revealed Physician's Orders for a NAS (No Added Salt) diet, pureed texture, h… | 2020-09-01 |
| 1652 | 1652 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 314 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Infection Control: Hand Hygiene, the facility failed to ensure proper hand hygiene during a dressing change for Resident #22. The facility further failed to accurately assess and stage a sacral pressure ulcer for Resident #22 for 1 of 2 residents reviewed for Pressure Ulcers. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. During an interview on 10/31/2016 at approximately 12:34 PM with Licensed Practical Nurse (LPN) #4 stated that Resident #22 has a chronic Stage IV pressure ulcer to his/her sacral area. Review of the physician's order on 11/2/2016 at approximately 10:10 AM revealed a physician's order to cleanse the sacral wound with normal saline and to pack wound with [MEDICATION NAME] and cover with an Allevyn dressing. During an observation of wound care on 11/2/2016 at approximately 10:10 AM the Licensed Practical Nurse (LPN) #2 knocked on the door, and asked permission to enter. LPN #2 explained the procedure, and this surveyor asked permission to observe wound care. LPN #2 washed his/her hands and applied gloves. He/she then removed the soiled dressing, removed his/her gloves and washed his/her hands. The LPN #2 cleansed the wound with saline soaked gauze x 3 and dried the area x 2. The nurse then cut off a piece of the [MEDICATION NAME] dressing and used a cotton applicator to pack the wound with the [MEDICATION NAME]. He/she then covered the wound with the Allevyn dressing. LPN #2 failed to remove his/her gloves after cleansing the wound and applying the [MEDICATION NAME] and covering the wound with the Allevyn dressing. An interview on 11/2/2016 at approximately 10:20 AM with LPN #2, the Wound Nurse, stated, he/she recalls that after cleansing the wound he/she did not remove his/her gloves and cleanse his/her hands before packing the cleansed wound with [MEDICATION NAME] and applying the clean dressing. Review on 11/2/201… | 2020-09-01 |
| 1653 | 1653 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 315 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess and provide care and services to achieve as much normal urinary function as possible for one of three sampled residents reviewed for urinary incontinence. There was no bladder assessment completed or plan implemented to attempt to improve urinary incontinence for Resident #83 who had a decline in continence. The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review of the 6-24-2016 Admission Minimum Data Set (MDS) Assessment revealed that Resident #83 was coded as being occasionally incontinent (less than 7 episodes of incontinence). On the 8-15-16 5-Day and 9-5-2016 30-Day/Quarterly MDS Assessments, the resident was noted as frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). S/he required extensive assistance with transfers, toileting, and hygiene. The MDS noted no toileting plan had been attempted. Review of the 8-8-16 Initial Care Plan on 11-2-16 at 9:02 AM revealed that the facility identified the resident's incontinence upon readmission. Review of computerized assessments revealed no bladder assessment had been completed to identify predisposing and contributory factors to having urinary incontinence. The 6-24-16 initial bladder assessment was blank and the 9-16 assessment was noted as past due. Further review of the record revealed no evidence of evaluation or monitoring of voiding patterns. Review of the Care Plan at 9:32 AM on 11-3-16 revealed incontinence identified as a concern only in relation to maintenance of skin integrity. Interventions to maintain intact skin integrity x 90 days included: Staff will assist with toilet as needed/requested and provide incontinence care management as needed. There was no Care Plan developed with individualized interventions to address the incontinence. Review of Progress Notes and Incident Reports at 3:10 PM on 11-2-16… | 2020-09-01 |
| 1654 | 1654 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 323 | E | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that assistive devices were correctly and consistently applied for one of two sampled residents reviewed for falls/accidents. Although the resident had been assessed at risk for falls and had sustained multiple falls, Resident #83 did not have fall prevention measures in place as required by physician's orders [REDACTED]. Resident #83 had thirteen falls in a 3 month period with limited changes in interventions to prevent recurrence. The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review of the 8-15-16 5-day and 9-5-16 30-Day Minimum Data Set (MDS) assessments revealed that the resident had a Brief Interview for Mental Status score of 1, indicating severe cognitive impairment. Signs of delirium included: inattention, disorganized thinking, trouble concentrating, short tempered, and easily annoyed. Extensive assistance was required for transfers and toileting. Record review on 11-2-16 at 9:19 AM revealed a 7-7-16 physician's orders [REDACTED]. Review of the Care Plan at 9:32 AM on 11-3-16 revealed a focus area including fall risk, history of falls, and history of removing/destroying alarms. Interventions included to ensure alarms are in place and functional. Review of Progress Notes and Incident Reports at 3:10 PM on 11-2-16 revealed that Resident #83 sustained eleven falls between 8-20-16 and 10-30-16. (1) On 8.20-16 at 10:11 AM, the nurse was Called to sun porch and observed resident sitting on floor in front of w/c (wheelchair). She (he) had slid from under waist belt. Review of the report revealed that a seat belt was in place but neither the sensor alarm or tab alarm was checked to indicate it was in place at the time of the fall. Staff was counseled on proper application of the restraint. (2) On 8-23-16 at 4:31 PM, Resident was sitting at nurses station and slid from underneath the safety belt. Review of the report revealed that neithe… | 2020-09-01 |
| 1655 | 1655 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 431 | E | 0 | 1 | TQ9911 | Based on observations, interviews and review of the facility policy titled, Policies for Ordering, Charting and Administering Drugs. and Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure the medication cart on the A Wing was locked while unattended, failed to ensure a container of medications were secured and not stored on top of the medication cart on the A Wing while unattended. The facility further failed to ensure narcotics were secured and double locked on the A Wing. The facility additionally failed to ensure expired medications were removed from the medication carts on the A and B Wings and not stored with other medications for resident use for 2 of 2 units observed for stored, secured and expired medications. The findings included: An observation was made on 11/1/2016 at approximately 8:30 AM during med pass of a container of unsecured medications left unattended on the A Wing by Licensed Practical Nurse (LPN) #3. During an interview on 11/1/2016 at approximately 8:34 AM with LPN #3, he/she stated, We usually take the medications out and leave them covered on the medication cart while we pass meds. LPN #3 then removed the container of unsecured medications and placed them in the medication storage room. LPN #3 went on to say that there is not room for them to be locked on the medication cart. An observation was made on 11/2/2016 at approximately 8:04 AM during med pass, LPN #1 left the medication cart unlocked and unattended in the hallway while administering medications to a resident in his/her room. During an interview on 11/2/2016 at approximately 8:05 AM LPN #1 confirmed the findings and stated, I don't usually do that. An observation on 11/2/2016 at approximately 2:00 PM of a medication cart on the B Wing revealed the medication Lorazepam 0.5 mg (milligram) tablets, Manufactured by Qualites with Lot #8003, 3 tablets had expired on 9/30/2016. An interview on 11/2/2016 at approximately 2:00 PM with LPN #4 verified the findings and removed the medic… | 2020-09-01 |
| 1656 | 1656 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 464 | E | 0 | 1 | TQ9911 | Based on observations and interviews, the facility failed to provide adequate dining furnishings and/or space on one of two units to accommodate dining. The Unit A sun porch was being used for dining but only had one table to accommodate 4 residents. Seven to eight residents ate off of overbed tables for all meals served in that area. The findings included: During meal observation on 11-2-16 at 8:30 AM, four residents were served at the one table in the room while 7 were eating off overbed tables in the Unit A porch. At 1:14 PM on 11-2-16, 3 of 4 residents seated at the table on the porch were different than earlier in the day. When asked about seating for the meal and how it was decided who sat at the dining table, Certified Nursing Assistant (CNA) #1 stated it was done on a first come, first served basis. During observation on 11-3-16 at 12:58 PM, 4 residents were eating at one table on the sun porch on A Hall. Three of the four were different residents than previous observations. Eight residents were eating off of overbed tables. One resident was eating in the hall near the nursing station. When asked if there was a reason why the resident was eating in the hall, CNA #6 stated,No. Sometimes it's crowded on the porch-not necessarily today though. During all meal observations, seating was available in the main dining room. During an interview at 8:40 AM on 11-3-16, Social Services provided a policy on dignity which also included providing a homelike environment; meeting the needs and desires of residents in terms of . dining . | 2020-09-01 |
| 1657 | 1657 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 502 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Physician Notification of Diagnostic Testing, the facility failed to ensure lab test were done as ordered by the physician or reported timely for Residents #60, #61, #64 and Resident #83 for 4 of 36 residents reviewed with lab testing ordered. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 11/1/2016 at approximately 4:41 PM of the medical record for Resident #61 revealed a physician's order to draw a [MEDICATION NAME] blood level monthly. Further review on 11/1/2016 at approximately 4:41 PM of the medical record for Resident #61 revealed no [MEDICATION NAME] blood level results for the month of August. Resident #61 was currently receiving [MEDICATION NAME] 10 milliliters via a Gastrostomy tube for [MEDICAL CONDITION] During an interview on 11/2/2016 at approximately 1:03 PM with the Assistant Director of Nursing, he/she confirmed that the [MEDICATION NAME] blood level had not been drawn as ordered by the physician. Review on 11/2/2016 at approximately 1:30 PM of the facility policy titled, Physician Notification of Diagnostic Testing, states under Policy, number 9 states, Written/verbal orders given related to diagnostic testing will be entered into the chart and acted upon by the licensed nurse receiving the orders. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review at 12 PM on 11-2-16 revealed Physician's Orders for a CMP (Comprehensive/Complete Metabolic Profile) every 6 months and K+ (Potassium) level every 3 months. Review of laboratory reports with the Assistant Director of Nursing (ADON) at 1:55 PM on 11-2-16 revealed that a Basic Metabolic Profile (BMP) was completed on 3-2-16 instead of a CMP. Review of K+ levels with the ADON revealed that levels were drawn on 10-3-16, 7-1-16, 3-2-16 in conjunction with a BMP, 1-4-16, and 10-7-15. The ADON stated,It got done in (MONTH) instead of (MON… | 2020-09-01 |
| 1658 | 1658 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2016-11-03 | 505 | D | 0 | 1 | TQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the physician of abnormal laboratory results for three of 36 sampled residents reviewed for laboratory services. (Residents #60, #61, and #83) The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Record review on 11-2-16 at 9:19 AM revealed multiple abnormal laboratory results without evidence of physician notification: -A Prothroubin Time/International Normalization Ratio (PT/INR) was completed on 10-26-16. The PT was 29.8 seconds (high) with a reference range of 10.8-14.8. The Assistant Director of Nursing (ADON) signed the report as reviewed on 10-27-16, but there was no evidence of physician notification. -A PT/INR was completed on 10-19-16. The PT was 30.6 seconds (high). The ADON signed the report as reviewed on 10-24-16, but there was no evidence of physician notification. -A Complete Blood Count (CBC) was completed on 10-19-16. The Red Blood Count (RBC) was 3.76 M/uL (low) with a reference range of 4.10. 5.10. The Hemoglobin was 9.8 g/dL (low) with a reference range of 11.7-15.7. The Hematocrit was 29.6% (low) with a reference range of 35.0-47.0. The ADON signed the report as reviewed on 10-24-16, but there was no evidence of physician notification. -A PT/INR was completed on 10-12-16. The PT was 32.8 seconds (high). The ADON signed the report as reviewed on 10-13-16, but there was no evidence of physician notification. -A PT/INR was completed on 9-26-16. The PT was 26.8 seconds (high). The ADON signed the report as reviewed on 9-27-16, but there was no evidence of physician notification. -A PT/INR was completed on 9-21-16. The PT was 23.5 seconds (high). The ADON signed the report as reviewed on 9-21-16, but there was no evidence of physician notification. -A CBC was completed on 9-7-16. The RBC was 3.72 M/uL (low) with a reference range of 4.10- 5.10. The Hemoglobin was 10.0 g/dL (low) with a reference range of 11.7-15.7. The Hematoc… | 2020-09-01 |
| 5090 | 5090 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 156 | C | 0 | 1 | OJWN11 | Based on review of residents' funds and interview, the facility failed to complete 2 of 3 required Centers for Medicare and Medicaid Services(CMS) -Notice of Medicare Non-Coverage (NOMNC) forms and 3 of 3 Medicaid Liability Notices and Beneficiary Appeal Rights, accurately and in a timely manner for sampled residents discharged from Medicare A.(Resident #28, #34, & #50) The findings included: Review of the Notice of Medicare Provider Non-Coverage (CMS- NOMNC) on 7/22/15 revealed Resident #34 and #50 had incomplete forms. There was incomplete information related to the effective date of coverage, when services would end and what type of services would end. Further review revealed the responsible party signed the incomplete forms but did no date the forms. During the review no Liability Notices(SNFABN-CMS or 1 of 5 Denial Letters) were found for Residents #28, #34, & #50. On 7/23/15 at 10:41 AM, during an interview with the Social Service Director, he/she confirmed the CMS- NOMNC were not complete and no SNFABN-CMS or 1 of 5 Denial Letters had been completed for Residents #28, 34, & 50. | 2019-05-01 |
| 5091 | 5091 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 241 | D | 0 | 1 | OJWN11 | Based on observation and interview, the facility failed to provide an environment to promote dignity of residents during the dining experience. During 1 of 2 observations of dining, staff were observed placing clothing protectors on residents without asking residents' permission. The findings included: On 7/20/15 at 12:38 PM, during the lunch observation, Certified Nursing Assistants(CNA's) #5 and #6 were observed to place a towel over residents without asking the residents' permission. During an interview with CNA #5 on 7/23/15 at 3:13 PM, he/she stated residents should be asked if they would like a clothing protector or towel prior to placing one on the resident. No policy was provided during the survey process related to dignity and dining. | 2019-05-01 |
| 5092 | 5092 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 248 | D | 0 | 1 | OJWN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests, physical, mental and psychosocial well being for 1 of 3 residents reviewed for activities. Resident #11. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. An observation on 7/20/2015 at approximately 1:55 PM revealed resident #11 in bed, sleeping at intervals, no activities are observed on this date. An observation on 7/21/2015 at approximately 12:06 PM revealed resident #11 in bed, sleeping at intervals, no activities are observed which included this resident on this date. An observation on 7/22/2015 at approximately 10:12 AM revealed resident #11 in bed and no 1 to 1 or out of room activities are observed on 7/22/2015 in which resident #11 is included. Review on 7/22/2015 at approximately 2:10 PM of an Activities assessment dated [DATE] by the Activity Director under Bb Activity Involvement, Time involved in Activities, coded 2 - Some from 1/3 to 2/3 of the time. Section B3a. Location of Activity is coded 1 - Own room. Under B4a. Activity Pursuit Patterns - Preferences - Specifics #6a states, Resident will attend church services 2 times weekly in the geri-recliner. D2a under, Resident Interview Summary - General Demeanor - states, resident not understanding questions - goes to group activities for stimuli through music church service, etc. Review on 7/22/2015 at approximately 2:32 PM of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 2 days, 4/15/2015 and 4/26/2015. No other activities were documented on the attendance form for (MONTH) (YEAR). Review of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 5/10/2015 and 5/20/2015. No other activities were documented on the activity attendance form for (MONTH) (YEAR). Review of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 2 days 6/10/15 and 6/27/2015. No other activities… | 2019-05-01 |
| 5093 | 5093 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 253 | E | 0 | 1 | OJWN11 | Based on observations, interview, an environmental round with the Maintenance Director and review of the facility's Routine Duty Schedule, the facility failed to provide housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable interior. The facility had multiple areas of bent window blinds, scuffed and damaged walls, broken outlet, damaged chest of drawers, dust on bathroom vents, peeling ceilings, chipped paint on door facings, a tear in a cushion, rusty paper towel holders, wax build-up on floors, spackle coming off ceiling and baseboards coming away from wall. The findings included: Random observations were made in the facility during the survey process as follows: Room 127- window blinds bent, room wall with scuff marks; Room 134- window blinds bent; Room 137- torn area on wall near head of bed; Room 139A- broken outlet on wall; Room 141B- broken slats in air conditioner, broken chest of drawer; Room 143- peeling ceiling, dust on vent in bathroom; Room 144-scuffed walls in room, tear in cushion at head of bed; Room 145- chipped noted on bathroom door; Room 148- broken slats in air conditioner, scuffed walls, wax build-up noted on floor, dust on bathroom vent; Room 150- dark area noted on ceiling, wallpaper peeling from ceiling, rusty paper towel holder; Room 152- scuffed door Room 154- hole in wall beside bed, bathroom with wax build-up, scuffed doors, ceiling with cracks, dust on bathroom vent; Room 157- bathroom walls dirty, back of commode at base of the flusher in need of cleaning, paper towel holder with rust like substance, bathroom entrance doors damaged; Room 158- walls scratched and scuffed Room 160- part of the towel holder is sharp and rusty, bathroom doors scuffed, peeled area on wall near soap dispenser in bathroom; Room 162- bathroom floor stained and has holes in the linoleum, scuffs on bathroom walls; Room 164- bathroom baseboards coming away from wall, bathroom doors scuffed and scratched, dark build- up around door facing at the entrance to bathroom… | 2019-05-01 |
| 5094 | 5094 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 279 | D | 0 | 1 | OJWN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a Plan of Care with measurable goals and interventions to address the participation in activities of choice in accordance with the assessment, resident's wishes and current standards of practice for 1 of 3 residents reviewed for activities. Resident #11. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 7/22/2015 at approximately 2:32 PM of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 2 days, 4/15/2015 and 4/26/2015. No other activities were documented on the attendance form for (MONTH) (YEAR). Review of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 5/10/2015 and 5/20/2015. No other activities were documented on the activity attendance form for (MONTH) (YEAR). Review of the Activity 1 to 1 in room visits for (MONTH) (YEAR) included 2 days 6/10/15 and 6/27/2015. No other activities were documented on the attendance form for (MONTH) (YEAR). Review of the activity 1 to 1 in room visits for (MONTH) (YEAR) included 2 days, 7/11/2015 and 7/20/2015, no other activities or 1 to 1 activities were documented for (MONTH) (YEAR). During an interview on 7/22/2015 at approximately 2:40 PM with the Activity Director, this surveyor if resident #11 had attended any out of room activities and he/she stated, No and went on to say, he/she is not able to go to out of room activities. Review of the Comprehensive Plan of Care on 7/22/2015 at approximately 1:02 PM revealed a Focus area of Memory Deficit. The target goal date is 10/20/2015 and reads, needs anticipated by staff and appropriate socialization x 90 days. The intervention that included activities states, Staff will assist/encourage resident to participate in activities. Staff will encourage resident to participate in activities outdoors. No specific activities for Resident #11 were listed on the Plan of Care to include 1 to 1 in room visits/activities. | 2019-05-01 |
| 5095 | 5095 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 309 | E | 0 | 1 | OJWN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a physician ordered, daily fluid restriction was monitored and recorded for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. (Resident #33) The findings included. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review of the medical record on 7/23/2015 at approximately 4:55 PM revealed Resident #33 was on a 500 milliliter (ml) fluid restriction daily. No documentation could be found in Resident #33's medical record on the amount of fluid dietary versus nursing would provide. An interview on 7/23/2015 at approximately 6:45 PM with Licensed Practical Nurse (LPN) #5, the evening nurse on the B Wing, stated he/she did not know where to find the documentation for the 500 ml fluid restriction for resident #33 and was unaware of how much fluid dietary provided and how much nursing provided. During an interview on 7/23/2015 at approximately 6:50 PM with the Director of Nurses (DON) he/she too did not know where it is documented or how much is allotted each shift or the amount given the resident by dietary and nursing for resident #33. Review on 7/23/2015 at approximately 7:55 PM of a form provided by the DON titled, Intake and Output - 500 ml Fluid Restriction/Day listed dates from 6/2/2015 through 7/21/2015 with totals daily of 300 to 500 mls with most days stating, Not Applicable. | 2019-05-01 |
| 5096 | 5096 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 371 | E | 0 | 1 | OJWN11 | Based on observations, interviews, and review of the Food Code U.S. Public Health Service FDA 2013, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen as evidenced by the following: staff touching ready-to-eat food with bare hands during meal service, failing to date food when opened, remove expired food items from walk-in refrigerator and dry good storage, secure hair with hair restraint in food preparation areas, remove ice chests with cracked areas, and observation of a brown substance on the vent above the chest freezer. This has the potential to effect all residents receiving a therapeutic diet. The findings included: During a random observation of the lunch meal distribution on 7-20-15 at approximately 12:50 PM in the Dining Room, observation revealed Certified Nursing Assistant (CNA) #3 removed saltines from the packaging with his/her bare hands for 1 resident. During an interview on 07-23-15 at approximately 1:21 PM with CNA #3, he/she stated, Oh, I thought I had shaken them out. On 07-23-15 at approximately 9:00 AM, in the presence of the Dietary Cook, random observation in the Main Kitchen revealed the following: Dry Good Storage: one 5 pound bag of Quaker Grits Quick 5 Minutes opened without an open date and a hole in the bottom of the bag noted with grits spilling out 2 ice chests for residents' use with cracked areas inside the lids Brown substance on the vent above the chest freezer Walk-in Refrigerator: Two 5 pound bags of Cross Valley Farms shredded cabbage with label noted best if used by 07-21-15 During an interview with the Dietary Cook on 07-23-15 at approximately 10:00 AM, he/she verified the above findings. On 07-23-15 at approximately 5:00 PM, the Director of Nursing failed upon request to produce a facility policy related to the above dietary issues. Review of the Food Code U.S. Public Health Service FDA 2013 revealed in Chapter 3, Part 3-3: Protection from contamination after receiving food, Subpart 3-301.11, Preventing Contamination fr… | 2019-05-01 |
| 5097 | 5097 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 431 | E | 0 | 1 | OJWN11 | Based on observations and interviews, the facility failed to ensure expired medications were removed from 1 of 2 medication rooms and not stored with other medications for resident use. The facility further failed to ensure 1 opened pack of gauze and 1 opened pack of non-adherent pads were removed from 2 of 2 treatment carts. The facility also failed to remove 1 package of expired sterile gloves, 9 packages of dressings either opened without an open date or expired, and 1 package of Povidone-Iodine Swabsticks which had expired from 2 of 2 supply rooms. The findings included: During a review of the A Hall Medication Room on 07-22-15 at approximately 8:38 AM, observation revealed one package of Phenadoz 25 milligrams (mg) Suppositories, Rectal, count of 12, labeled to be refrigerated, Lot number (#) 66, manufactured (mfd.) by Perrigo, expiration date of 05-2016, stored on a shelf in the medication room. During an interview on 07-22-15 at approximately 8:38 AM with Licensed Practical Nurse (LPN) #3, he/she verified the above finding and revealed the suppositories should have been refrigerated. , During a review of the A Hall Supply Room on 07-22-15 at approximately 8:38 AM, observation revealed the following: 1 package (pkg) of Esteem Sterile Polyisoprene Powder-Free Surgical Gloves with use by date of 01-2013, Lot # 03TS 639, manufacturer Cardinal Health 1 pkg. of Medline Skintegrity Hydrogel Dressing, 4 inches x 4 inches, opened without an open date, expiration date, or Lot #, manufacturer Meline Industries Xerofoam Petrolatum Dressing 5 inches x 9 inches, use by date of 01-2013, opened, Lot # 011, manufactured by Tyco Xerofoam Petrolatum Dressing 5 inches x 9 inches, use by date of 01-2013, unopened, Lot # 05, manufactured by Tyco Xerofoam Petrolatum Dressing 5 inches x 9 inches, use by date of 01-2013, unopened, Lot # 0F, manufactured by Tyco Xerofoam Petrolatum Dressing 5 inches x 9 inches, use by date of 10-2006, unopened, Lot # 6A, manufactured by Tyco Xerofoam Petrolatum Dressing 5 inches x 9 inches, use by … | 2019-05-01 |
| 5098 | 5098 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 441 | E | 0 | 1 | OJWN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy titled Handling and Storage of Clean and Soiled Linen, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Observations of the laundry revealed soiled items not bagged and during observation of the medication pass, 1 of 3 nurses were observed handling medications with his/her bare hands. Personal care items were not covered in resident bathrooms. The findings included: Random observation of the laundry on 7/20/2015, 7/22/15, and 7/23/15 revealed two uncovered carts with soiled laundry items which were not bagged. On 7/23/15, Laundry Worker #1 confirmed the soiled items were not bagged. Review of the facility policy titled Handling and Storage of Clean and Soiled Linen revealed under the procedure section 1 the following: Soiled or 'dirty linen' is: a. Bagged at site of collection and is transported to a specific area in a closed 'soiled linen' bag. Minimal handling of soiled linen is advised. b.-Soiled linen is placed in a covered linen storage receptacle. Random observations during the survey of rooms [ROOM NUMBERS] revealed a urine collection hat stored on the bathroom grab bar. During environmental rounds with the Maintenance Director on 7/23/15 at 6:00 PM, these items were observed. Observation during medication administration on 7/22/2015 at approximately 8:24 AM revealed Licensed Practical Nurse (LPN) #1 removing pills from the blister card, putting them in his/her hand then putting them in the medication cup for residents to ingest. An interview on 7/22/2015 at approximately 8:40 AM with LPN #1 confirmed that he/she has touched the resident's medication with bare hands. He/she also stated, it is difficult to remove the medications from the blister cards without touching them. Review of the facility policy on 7/23/2015 at … | 2019-05-01 |
| 5099 | 5099 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-07-23 | 460 | D | 0 | 1 | OJWN11 | Based on observations and interview, the facility was observed to have rooms with privacy curtains which were too short to allow the privacy curtain to extend around the bed to provide full privacy for residents in each room reviewed. (5 of 17 residents reviewed) The findings included: Observations of rooms 139, 152, 155, 165, and 167 on 7/20/15 and 7/21/15 revealed the privacy curtains were too short and an opening was noted which did not provide full visual privacy. On 7/23/15 at 6:00 PM, during observations of the rooms with the Maintenance Director, he/she confirmed the privacy curtains were short and did not provide full visual privacy. | 2019-05-01 |
| 5679 | 5679 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2018-02-10 | 580 | E | 0 | 1 | C32011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician related to ordered weights not done for one of one resident reviewed with physician orders [REDACTED].#41) The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Record review on 2/8/18 at 11:02 AM revealed the resident had a physician's orders [REDACTED]. Review of the Medication Administration Sheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #41 was not weighed on 10/7/17, 10/24/17, 11/12/17, 11/14/17, 11/19/17, 11/22/17, 12/9-10/17, 12/12-16/17, 12/21/17, 12/23-27/17, and 12/30/17. Further review revealed with the exception of five times, Resident #41 refused to be weighed. Further review of the medical record revealed there were no other weights recorded for the above days nor had the physician been notified of the resident's refusal to have weights done. During an interview with the Director of Nursing, after reviewing the information, confirmed the resident had not been weighed and the physician should have been notified. | 2018-10-01 |
| 6121 | 6121 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 155 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to assess Resident #47 to determine decision-making capacity for health care decisions. (1 of 20 sampled residents reviewed for the ability to make health care decisions.) Resident # 47's decision related to advanced directives were signed for by a family member without first determining the resident's ability to make his/her own healthcare decisions. The findings included: The facility admitted Resident #47 with the [DIAGNOSES REDACTED]. Review of the resident's medical record on 4/15/14 at approximately 3:26 PM, revealed Resident #47 had a Do Not Resuscitate (DNR) order as an Advance Directive. Further review of the medical record revealed there was no documentation the resident had been assessed for decision-making capacity for health care decisions. Review of the Request Concerning Life-Prolonging Procedures form noted that the resident was a DNR and it had been signed by the resident's daughter During an interview on Interview on 4/16/14 at approximately 10:13 AM with the Social Services Director, s/he stated that Resident #47's son (not the daughter) was the designated Health Care Power of Attorney and additionally verified that the resident had not been assessed for decision-making capacity. | 2018-05-01 |
| 6122 | 6122 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 226 | E | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, review of the facility's reportable investigative documents, and the facility's policy titled Reportable Accidents/Incidents, the facility failed to ensure incidents involving allegations of resident abuse were reported to the appropriate State Agency as required by federal regulation for 2 of 2 residents reviewed for allegations of abuse. Resident #17 and Resident #29 reported allegations of verbal abuse by staff members that were not investigation and or reported. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. During an interview on 04-14-16 at approximately 9:04 AM with Resident #17, he/she alleged verbal abuse by staff related to refusal of assisting with personal care. Record review on 04-16-14 of Resident #17's record revealed there was no documentation available related to the alleged verbal abuse by staff toward Resident #17. During an interview on 04-16-14 at approximately 11:00 AM with the Assistant Director of Nursing, he/she revealed the allegation of verbal abuse by Resident #17 had been reported to the Director of Nursing and further verified the above incident of alleged verbal abuse had not been reported to the Bureau of Certification as required by federal regulation. The Director of Nursing was unavailable for interview. The facility admitted Resident #29 with the [DIAGNOSES REDACTED]. During an interview with Resident #29 on 4/14/14 at approximately 12:50 PM , during an individual interview, the resident stated: Staff called me lazy and yelled at me and cursed. During an interview with the Social Service Director on 4/15/14 at approximately 10:37 AM, s/he stated: This occurred June 20, 2013, Resident #29 stated to me that a third shift CNA (Certified Nursing Assistant) told the resident to kiss his/her behind when the resident requested to be put to bed. The complaint was reported to the Administrator and Director of Nursin… | 2018-05-01 |
| 6123 | 6123 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 253 | E | 0 | 1 | 0N2F11 | On the days of the survey based on observations, interview and review of the facility policy title Maintenance Services, the facility failed to to provide maintenance services necessary to maintain an orderly, comfortable interior in good repair as evidenced by multiple resident wheelchairs with torn padding, damage to walls and ceilings in resident rooms on 2 of 2 units. The findings included: Review of the facility policy titled Maintenance Services dated 6/27/07 revealed, The maintenance department is responsible for maintaining the building, grounds, and equipment .Providing routinely scheduled maintenance services to all areas During the days of the survey random observations were made of resident wheelchairs with torn padding which caused the foam cushioning to be exposed in the following rooms: 126B, 130A 135A, 137, 139. The arm rest was observed to be loose on the chair being used by the Resident Council President. On 4/17/14 at approximately 11:00 AM, a facility walk-through with the Maintenance Director was conducted which revealed the following: Room 142 - The popcorn ceiling was loose and hanging down over the toilet in the bathroom. Rooms 135 and 137 had multiple streaks/ stains, scratches and tears on the walls. Room 139 had a cracked ceiling which was located above the resident's bed. A wing - The ceiling vent was observed with no filter. B wing - Ceiling was observed to have cracks. The baseboards on Unit A and B were observed to be heavily soiled with multiple scrapes and tears. During an interview with the Maintenance Director on 4/17/14 at approximately 11:25 AM, s/he confirmed the surveyor's findings. The Maintenance Director stated there was no system in place to monitor the condition of resident's wheelchairs. The Maintenance Director was unable to provide any routine Maintenance logs. | 2018-05-01 |
| 6124 | 6124 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 279 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the facility's policy entitled, [MEDICAL TREATMENT] Residents Policy and Procedure, the facility failed to develop a comprehensive care plan for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The care plan for Resident #62 did not comprehensively address [MEDICAL TREATMENT] related care needs as outlined in the facility's policy. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. The care plan was reviewed related to approaches and interventions for [MEDICAL TREATMENT]. Review of the care plan indicated staff was to monitor and check the [MEDICAL TREATMENT] site for thrill and bruit as ordered. Review of the physician's orders [REDACTED]. Upon request, a copy of the facility's policy entitled, [MEDICAL TREATMENT] Residents Policy and Procedure was provided to the surveyor. Review of the policy revealed nine guidelines listed in the Procedure section of the policy. Step #2 of the Procedure section stated, .after [MEDICAL TREATMENT] treatment and upon return to Ridgeland Nursing Center, the nurse will check for thrill and bruit, as she will daily thereafter. In addition, review of the care plan revealed no interventions or approaches related to monitoring or taking the resident's vital signs. Step #3 of the policy stated, No venipuncture or blood pressure will be taken in arm with shunt. Step #5 stated, Obtain vital signs of resident upon return from [MEDICAL TREATMENT]. Step #4 stated, Check graft or cath site for bleeding every shift. The care plan stated Staff will monitor for bleeding to fistula site to right arm as needed . Step #7 stated, Monitor for [MEDICAL CONDITION] and shortness of breath. If noted, call Physician. The care plan did not address this issue. During an interview on 4/16/14, the MDS (Minimum Data Set) Coordinator was asked to review Resident #62's care plan … | 2018-05-01 |
| 6125 | 6125 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 280 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise the Comprehensive Plan of Care for 2 of 23 sampled residents with care plans reviewed. Resident #45's careplan did not address Restorative Nursing Services for Range of Motion. Resident #55's careplan did not address the resident's weight loss of 27 pounds. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 4/15/2014 at approximately 12:15 PM revealed a physician's orders [REDACTED]. Review of Resident # 45's Comprehensive Plan of Care revealed he/she requires limited to total assistance with activities of daily living. The current care plan did not include the above mentioned physician's orders [REDACTED]. An interview on 4/17/2014 at approximately 9:52 AM with the Care Plan Coordinator verified the above findings. The facility admitted Resident #55 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Diabetes, and Depression. Review of Resident #55's medical record on 4/16/2014 at approximately 9:30 AM revealed a weight loss of 27 pounds from 11/2/2013 until 4/8/2014. Further review of Resident #55's record revealed dietary notes which stated, Resident consumes 50 to 75% of meals served and receives Health Shakes 2 times daily. Additional review of Resident #55's Comprehensive Plan of Care revealed a focus on Nutrition which stated, Resident has a history of weight gain since admission. An interview with the Care Plan Coordinator on 4/17/2014 at approximately 9:52 AM verified the weight loss and/or weight loss potential was not included in the Comprehensive Plan of Care. | 2018-05-01 |
| 6126 | 6126 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 309 | E | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, and interviews, the facility failed to provide the necessary care and services for 1 of 1 resident reviewed for [MEDICAL TREATMENT], 1 of 1 resident reviewed for Hospice, and 1 of 2 residents reviewed for pressure ulcers. The facility failed to maintain communication and coordinate care with Resident #62's [MEDICAL TREATMENT] center, failed to maintain documentation of Hospice staff visits for Resident #31, and failed to follow physician's orders [REDACTED].#11. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Record review indicated Resident #62 received [MEDICAL TREATMENT] three times weekly. Review of the medical record on 4/15/14 indicated that no [MEDICAL TREATMENT] communication sheets or other form of documentation between the [MEDICAL TREATMENT] center and the facility was contained in the medical record. On 4/15/14 at approximately 11:15 AM, Licensed Practical Nurse (LPN) #3 was asked where the [MEDICAL TREATMENT] communication sheets were located, LPN #3 stated that he/she did not know. LPN #3 left the unit and returned shortly with a copy of labs and [MEDICAL TREATMENT] center progress notes faxed from the [MEDICAL TREATMENT] center on 4/15/14. LPN #3 was asked again if the [MEDICAL TREATMENT] center sends information back to the facility concerning labs, new orders, or other information when Resident #62 returns from the [MEDICAL TREATMENT] center. LPN #3 stated, No, and indicated that staff normally calls the [MEDICAL TREATMENT] center and asks about labs. On 4/15/14 the Assistant Director of Nursing (ADON) provided documentation faxed from the [MEDICAL TREATMENT] center on 4/15/14. The ADON stated that he/she had asked for dietary notes from the center and had received a dietary progress note for April 2014. The ADON confirmed that no communication sheets from the [MEDICAL TREATMENT] center were located on the resident's record. T… | 2018-05-01 |
| 6127 | 6127 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 367 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide the physician prescribed diet for 1 of 3 sampled residents reviewed for nutrition. During 2 of 2 lunch meal observations, the facility failed to serve Resident #86 a Mighty Shake with the meals. The findings included: The facility admitted Resident #86 with [DIAGNOSES REDACTED]. An observation on 04-15-14 at approximately 12:53 PM of the lunch meal revealed Resident #86 did not receive a Mighty Shake. The diet slip from the resident's tray noted Mighty Shakes three times a day (t.i.d) were to be provided. A second observation on 04-16-14 at approximately 12:50 PM of Resident #86's lunch meal again revealed a Mighty Shake had not been served. During an interview on 04-16-14 at approximately 12:50 PM with Certified Nursing Assistant (CNA) #3, he/she, after observation of Resident #86's lunch meal tray, verified Resident #86 had not received the Mighty Shake. Record review on 04-16-14 of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02-27-14 for an Admission revealed in Section K: Swallowing/Nutritional Status #200 B. The Resident's Admission Weight was: 102 pounds. Record review on 04-16-14 of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03-20-14 for a Significant Change revealed in Section K: Swallowing/Nutritional Status #200 B. The Resident's weight was: 98 pounds. Record review on 04-16-14 of the Physician's Telephone Orders dated 04-09-14 revealed a physician's orders [REDACTED].i.d) with meals. Record review on 04-16-14 of the Comprehensive Care Plan dated 02-27-14, revised 03-20-14, and initiated 04-10-14 revealed a Focus Area of Risk for nutrition and hydration .i.e . with an Intervention of the following: Mighty Shake t.i.d as ordered. Record review on 04-16-14 of the emergency room (ER) Record dated 03-12-14 revealed Resident #86 had had an assessment in the ER for Shortness of Brea… | 2018-05-01 |
| 6128 | 6128 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 369 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to provide special eating equipment per the physician's orders [REDACTED]. Resident #86 did not receive meals in a sectioned plate for 2 of 2 lunch meals observed. The findings included: The facility admitted Resident #86 with [DIAGNOSES REDACTED]. Observations on 04-15-14 and 04-16-14 at approximately 12:50 PM of Resident #86's lunch meal revealed the meal had not been served in a sectioned plate. Record review on 04-16-14 of Resident #86's Comprehensive Monthly physician's orders [REDACTED]. Record review on 04-16-14 of the Comprehensive Care Plan dated 02-27-14 and revised 03-20-14 revealed a Focus Area of Risk for nutrition and hydration .i.e . with an Intervention of the following: Staff will ensure resident has sectioned plate with meals. During an interview on 04-16-14 at approximately 12:55 PM with Licensed Practical Nurse (LPN) #1, he/she, after observation of the lunch meal plate and record review, confirmed Resident #86 had not received his/her meal in a sectioned plate per the Comprehensive physician's orders [REDACTED]. | 2018-05-01 |
| 6129 | 6129 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 371 | F | 0 | 1 | 0N2F11 | On the days of the survey, based on observation, interviews, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 dietary areas observed. The deficient practice had the potential to effect 79 of 79 residents with meals processed by the Dietary Department. The facility failed to: Calibrate the food temperature probe (thermometer) accurately, clean ceiling vents, and prevent contamination in the bulk sugar bin. Additionally, the cleaning/sanitizing buckets did not have adequate chemical solution for sanitization. The findings included: On 4-13-14 at 4:09 PM, during the initial tour of the dietary department/kitchen area with Cook #1 an observation was made of 2 ceiling vents above the food preparation area and serving line with a heavy build-up of dust. A scoop was observed inside the bulk sugar bin. On 4-15-14 at 11:35 AM during an observation of the dietary department/kitchen area with the Certified Dietary Manager (CDM) revealed 2 red cleaning/sanitizing buckets that were ? filled with a cloudy liquid located under posted signs stating CHANGE WATER IN SANITIZE BUCKET EVERY TWO HOURS. The CDM used a Precision Chlorine Test Paper (Part # TP-101) to test the water for a sanitizing agent. The test strip after being submerged in the water read 0 Parts Per Million (PPM). The CDM verified there was not adequate sanitizing solution in the water. A repeat observation was made at the same time of the 2 ceiling vents above the food preparation area and serving line that remained with a heavy build-up of dust. The CDM verified the findings and was asked, Are the vents were on a routine cleaning schedule? The CDM stated No, that ' s the maintenance department job. On 4-15-14 at 11:45 AM, during an observation of the lunch meal serving line. Cook #2 calibrated the Fahrenheit food temperature probe to 0 degrees in a cup of ice water and then began to test the temperature of foods. The surveyor then asked Cook #2, What is the correct temperature for cal… | 2018-05-01 |
| 6130 | 6130 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 467 | E | 0 | 1 | 0N2F11 | On the days of the survey based on observation and interview the facility failed to provide sufficient bathroom ventilation in resident bathrooms on 2 of 2 units and a shower room on the A unit. This had the potential to affect all the residents who had the ability to use the restrooms and who used the shower room. The findings included: Observation on 4/15/14 at approximately 2:20 PM, the surveyor noticed an odor from Resident #1's bathroom. On 4/16/14 at approximately 3:33 PM, the surveyor still noticed an odor in Resident #1's bathroom. Resident #1 bathroom exhaust was tested by the surveyor and a facility staff member. The exhaust sysytem in Resident #1's bathroom was not functioning. During an environmental tour with the Maintenance director on 4/17/14 at approximately 11:20 AM, s/he confirmed that the residents bathrooms and shower room exhaust on the A and B unit were not functioning. S/he later stated that the fan belt broke and needed to be replaced. The Maintenance Director stated there was no system in place to monitor the functioning of the exhaust system. | 2018-05-01 |
| 6131 | 6131 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 502 | D | 0 | 1 | 0N2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interview, the facility failed to provide or obtain laboratory services to meet the needs of Resident #45. The facility failed to obtain [MEDICATION NAME] blood levels as ordered by the Physician. (1 of 1 sampled residents with a [MEDICATION NAME] level ordered and not obtained.) The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of Resident # 45's medical record on 4/16/2014 at approximately 4:40 PM revealed a physician's orders [REDACTED]. Further review of Resident #45's medical record revealed lab results for only 2 of 7 [MEDICATION NAME] levels that were ordered by the Physician. There were results in the medical record for the dates of 6/7/2013 and 3/20/2014. There were no [MEDICATION NAME] results found for 9/2012, 12/2012, 3/2013, 9/2013 and 12/2013. An interview on 4/16/2014 at approximately 5:02 PM with the Assistant Director of Nurses verified the above findings. | 2018-05-01 |
| 6519 | 6519 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-01-27 | 157 | G | 1 | 0 | Y38111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the physician that Resident #1 failed to have a bowel movement for at least seven days, 1 of 3 residents sampled related to constipation. The findings included: Cross refer to F-309 as it relates to the failure of the facility to notify Resident #1's physician when s/he failed to have a bowel movement for 7 days between 07/13/2014 and 07/19/2014. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] coded him/her with a BIMs (brief interview of mental status) of 9. S/he was coded as always incontinent of bowel and totally dependant for toileting. Review of the Nurse's Notes (Progress Notes) for July 2014 revealed no documentation that the physician was called regarding Resident #1 not having a bowel movement from from 07/13/2014 through 07/19/2014 (7 days). The notes documented on 07/24/2014 at 10:14 AM Per resident s/he has not had a bowel movement in 3 weeks . Abdomen is distended and bowel sounds hypoactive. Enema administered x 1. Awaiting to evaluate if enema effective. No additional documentation was found regarding the results of the enema. The next note at 1600 stated, Resident abdominal distended, MD called Magnesium [MEDICATION NAME] 30 cc Po (by mouth) x 1 now given per MD order. Resident with small amount of BM. Resident stated that s/he feels like s/he has to have more BM; 1800 Resident stated that s/he wanted to go to the hospital, called MD, s/he stated to send him/her to the hospital. Personal Care Ambulance Services called. On 07/25/2014 at 3:27 AM the facility called the hospital to check on the resident and was told s/he was admitted with a bowel obstruction. Review of Resident #1's Toileting documentation for July 2014 revealed that s/he had a medium bowel movement on 07/12/2014, seven days later on 07/20/2014 s/he had a medium bowel movement. The Toileting documentation indicated the resident had a medi… | 2018-01-01 |
| 6520 | 6520 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-01-27 | 282 | D | 1 | 0 | Y38111 | Based on record review and interview, the facility failed to follow the plan of care for Resident # 1 related to transfer assistance. Resident # 1 was transferred from his/her wheelchair without the assist of two persons as care planned (1 of 2 sampled residents reviewed with a careplan for transfer assist). The findings included: The surveyor reviewed Resident #1's closed medical record as part of a complaint inspection regarding a facility reported incident dated 07/20/2014. Certified Nurse Aide (CNA) #1 stated in a facility obtained witness statement dated 07/20/2014 that s/he used the Hoyer lift to move Resident #1 from his/her wheelchair to his/her bed. The PointClickCare Guide used by the CNA's indicated Resident #1 needed 2 person assistance for transfer. In an interview with Licensed Practical Nurse (LPN) #2 on 01/25/2015 at 2:35 PM s/he confirmed that CNA #1 told her/him at the time of the incident on 07/20/2014 that s/he lifted Resident #1 alone using the Hoyer lift. | 2018-01-01 |
| 6521 | 6521 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2015-01-27 | 309 | G | 1 | 0 | Y38111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide needed care and services to Resident #1, 1 of 3 residents sampled related to constipation. Resident #1 had a bowel movement (BM) on 7/12/2014 his/her next bowel movement was 7/20/2014, seven days later. The medical record revealed no information that the physician was notified regarding the residents failure to have a bowel movement. The BM on 7/20/2014 was documented on the Certified Nurse Aide (CNA) tracking tool as medium. Resident #1 complained of not having a bowel movement on 7/24/2014 and an enema was administered with no documented results. The physician was notified that the resident's abdomen was distended and s/he had hypoactive bowel sounds, magnesium [MEDICATION NAME] was given resulting in a small bowel movement. The resident was still uncomfortable and asked to be sent to the hospital. The resident was admitted to the hospital on [DATE] with a bowel obstruction. The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. There was no documentation in the resident's medical record of a history of constipation. The Quarterly Minimum (MDS) data set [DATE] coded him/her with a BIMs (brief interview of mental status) of 9. S/he was coded as always incontinent of bowel and totally dependant for toileting. Review of the Nurse's Notes (Progress Notes) for July 2014 revealed documentation on 07/24/2014 at 10:14 AM Per resident s/he has not had a bowel movement in 3 weeks . Abdomen is distended and bowel sounds hypoactive. Enema administered x 1. Awaiting to evaluate if enema effective. No additional documentation was found regarding the results of the enema. The next note at 1600 stated, Resident abdominal distended, MD called Magnesium [MEDICATION NAME] 30 cc Po (by mouth) x 1 now given per MD order. Resident with small amount of BM. Resident stated that s/he feels like s/he has to have more BM; 1800 Resident stated that s/he wanted to go to … | 2018-01-01 |
| 7613 | 7613 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 159 | C | 0 | 1 | T83011 | On the days of the survey, based on record review and interview, the facility failed to obtain the appropriate signature (s) during withdrawal transactions from the residents' fund account. Funds from the residents' petty cash account were issued to residents or responsible party without signature (s). The findings included: On November 28, 2012 at 9:55 AM, during an interview with the Administrator regarding withdrawal from the residents' fund account revealed that there are no signature (s) obtained during withdrawal transaction from the residents' petty cash fund account. The Administrator presented this surveyor with a copy of the Trust Fund Receipt. Review of the Trust Fund Receipt revealed notation of the resident's name, the amount withdrawn, and the date, however, there was no notation of the resident's signature. This surveyor asked the Administrator how does s/he account for the withdrawal transaction from the residents' fund account without signature (s). She stated The residents' have never signed for as long as I have been working here. | 2016-12-01 |
| 7614 | 7614 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 160 | C | 0 | 1 | T83011 | On the days of the survey, based on record review and interview, the facility failed to convey the residents' personal funds to The Estate of the residents' name or according to probate authorization for 5 of 5 sampled residents' reviewed for conveyance of funds. The finfings included: On 11/28/2012 at 9:55 PM, record review of the conveyance of funds revealed that the residents' personal funds were not administered to the Estate of the residents' name or according to probate authorization. During an interview with the Administrator, s/he stated that s/he was not aware that the funds needed to be issued to the Estate of the resident. S/he stated that s/he has always written the checks to the responsible party. | 2016-12-01 |
| 7615 | 7615 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 241 | D | 0 | 1 | T83011 | On the days of the survey, based on random observations and interviews, the facility failed to promote care for Residents in a manner that enhanced their dignity and respect related to two of two random observations of Residents observed during meal time. The findings included: During a random observation on 11/28/12 at approximately 12:40pm, two Residents were eating their noon meal sitting in wheelchairs at the nurses's station on the B wing. A third Resident was observed to be sleeping while sitting in a wheelchair located between the two Residents eating their noon meals. During an interview with LPN (Licensed Practical Nurse) #4 on 11/28/12 at 12:50pm, s/he stated that The Resident sleeping needs to be fed his/her meal. Further observation on 11/28/12 at approximately 1:00pm of the third Resident, he/she continued to be sitting at the nurses station sleeping between the two other residents eating their meal. A random observation during mealtime on 11/27/2012 at 5:40 PM revealed 2 residents sitting in front of the nurses' station eating their dinner, while 2 residents sitting next to them were waiting to receive their meal On 11/27/2012 at 6:10 PM, random observation revealed the 2 residents who waited to receive their dinner, were being fed by the staff. On 11/29/2012 at approximately 1:50 PM during pre exit wiith the (DON) Director of Nursing present, the DON stated The residents were waiting to be fed by the staff. | 2016-12-01 |
| 7616 | 7616 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 323 | D | 0 | 1 | T83011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to ensure 1 of 4 residents reviewed for accident hazards received assistance devices to prevent accidents. Resident #3 did not have a chair alarm per the Physician's Telephone Orders. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 11-27-12 at 2:40 PM of Resident #3's Physician's Telephone Orders dated 11-11-12 revealed the following order: Chair alarm when out of bed (OOB) in wheelchair (w/c) related to (r/t) unassisted transfer and falls. Check every shift for placement and function. Further record review on 11-28-12 at approximately 10:00 AM of Resident #3's Care Plan last updated and reviewed on 11-26-12 revealed a Focus Area of .i.e. Resident #3 requires limited to total assist with Activities of Daily Living (ADLs) and has a high risk for falls. He/she uses a w/c for ambulation and has a decrease in ADLs believed to be related to bilateral knee pain. Additional review of the Care Plan revealed the following Interventions: Staff will ensure bed/chair alarm is in place and functioning properly. A random observation of Resident #3 on 11-28-12 at approximately 11:45 AM revealed Resident #3 sitting in a w/c without a chair alarm present. During an interview on 11-28-12 at approximately 1:40 PM with Certified Nursing Assistant (CNA) #1, he/she, after observation of Resident #3 sitting in a w/c, confirmed the chair alarm was not present but revealed it should have been. | 2016-12-01 |
| 7617 | 7617 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 329 | D | 0 | 1 | T83011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to attempt a gradual dose reduction for 1 of 13 sampled residents' reviewed for gradual dose reduction. There was no evidence Resident #2 received a gradual dose reduction for 2 medications. The findings included: On 11/28/2012 at 2:30 PM record review revealed that Resident #2 had been receiving [MEDICATION NAME] 100 mg (milligrams) and [MEDICATION NAME] 15mg since the initial order date of 9/28/2011 without evidence of a gradual dose reduction. Further review of the Pharmacy Review revealed no documentation addressing [MEDICATION NAME] and [MEDICATION NAME] or whether the medications should be reduced, discontinued or any combination of reasons. During an interview with the Licensed Practical Nurse (LPN), s/he stated that the Pharmacist would write the recommendation for a gradual dose reduction, then the recommendation is sent to the physician to review, sign and return. The LPN verified that there was no recommendation for a gradual dose reduction noted in Resident #2's medical records. On 11/29/2012 at 2:12 PM, this surveyor received a telephone call from the Pharmacy Consultant who stated that s/he did not make recommendations for a gradual dose reduction because s/he did not think the resident would benefit from a dose reduction because of his/her depression. This surveyor expressed concerns regarding the lack of documentation in the records to reflect the stated reason for not recommending a gradual dose reduction. The Pharmacist stated I would not make a recommendation if the resident didn't need a dose reduction. | 2016-12-01 |
| 7618 | 7618 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2012-11-29 | 332 | E | 0 | 1 | T83011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews and interviews the facility failed to ensure that it was free of a medication error rate of five percent or greater. The medication error rate was 9.8 % (percent). There were 4 errors out of 41 opportunities for error. There findings include: ERROR # 1: On 11/27/12 at approximately 11:30 AM, during observation of medication pass on A Wing , LPN (Licensed Practical Nurse) # 1 applied Pedinol, a topical antifungal gel, to the nail beds of the little fingers, index fingers and thumbs of both the left and right hand of Resident A. During medication reconciliation on 11/27/12, at approximately 12:10 PM, the physicians order dated 11/6/12 stated [MEDICATION NAME] 1 drop to small finger on right hand, both thumbs and left hand index finger three times daily for 30 days. On 11/27/12 at approximately 1:00 PM, LPN # 1 verified that he/she had not applied the medication as ordered by the physician on 11/6/12. ERROR # 2: On 11/27/12 at approximately 5:00 PM, during medication pass on B Wing, LPN # 2 administered carvedilol 3.125 mg (milligram) without food to Resident B. During medication reconciliation on 1/17/12 at approximately 5:30 PM the physicians order signed 10/30/12 revealed that carvedilol 3.125 mg was to be given with meals. On 11/27/12 at approximately 5:30 PM, LPN # 2 verified that carvedilol 3.125 mg had not been given with a meal. ERROR # 3: On 11/27/12 at approximately 5:00 PM, during medication pass on B Wing, LPN # 2 administered one puff of [MEDICATION NAME] 250/50 to Resident C and did not rinse the mouth afterwards. During medication reconciliation at approximately 5:30 PM, the physicians order dated 11/20/12 for [MEDICATION NAME] 250/50 stated to rinse mouth with water after use. On 11/27/12 at approximately 5:30 PM, LPN # 2 verified that he/she had not allowed Resident C to rinse mouth after administration of [MEDICATION NAME] 250/50. ERROR # 4: On 11/27/12 at approxim… | 2016-12-01 |
| 8912 | 8912 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2011-09-07 | 281 | D | 0 | 1 | O94H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, and interviews, the facility failed to ensure the Physician's Orders were carried out and standards of clinical practices established by the American Nurses Association related to medication administration were followed for 1 of 3 residents observed for Gastrostomy Tube Flush. (Resident#2) The findings included: The facility admitted Resident #2 on 1/11/08 with [DIAGNOSES REDACTED]. On 9/6/11 at 5:20 PM, Licensed Practical Nurse (LPN) #1, administered NAME] ([MEDICATION NAME]) F/C 40 milligrams (mg) in crushed form to Resident #2 via Gastrostomy Tube. On 9/6/11 at 5:25 PM, record review of Resident #2's Physician's Orders dated 8/16/11 revealed an order of NAME] F/C 40 mg tablet DR 1 tablet by mouth twice daily **DO NOT CRUSH OR CHEW**. Further record review of the Physician's Orders dated 8/16/11 revealed an order of May crush medications unless otherwise contraindicated and serve in food if necessary and appropriate as needed (PRN). On 9/6/11 at 5:25 PM, during an interview with LPN #1, she stated she always crushed the [MEDICATION NAME] tablet before giving even though it says not to. On 9/7/11 at 10:15 AM, during an interview with the pharmacist in charge, he stated the medicine should not be crushed due to decrease in potency. He further stated a granular form could be substituted. On 9/7/11 at 1:00 PM, during an interview with the facilities' pharmacy consultant whom reviewed residents' medication regimen stated, That slipped through the cracks and was not picked up by my computer that she (Resident#2) had a Gastrostomy Tube and that she was not receiving the medicine by mouth. | 2015-10-01 |
| 8913 | 8913 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2011-09-07 | 322 | D | 0 | 1 | O94H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and review of the facility policies titled Nasogastric Gastrostomy Tube Feeding and Hand Washing, the facility failed to ensure that a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services for 1 of 3 residents observed for a Gastrostomy Tube ([DEVICE]) Flush. During Resident #2's Gastrotomy Tube Flush, the nurse failed to provide infection precautions during medication preparation and administration, cleaning/disinfecting the Catheter Tip Syringe, and washing of the hands. The findings included: The facility admitted Resident #2 on 1/11/08 with [DIAGNOSES REDACTED]. On 9/6/11 at 5:20 PM, prior to performing Resident #2's Gastrostomy Tube Flush, Licensed Practical Nurse (LPN) #1 dispensed one [MEDICATION NAME] 40 milligram tablet into her hand, and dropped it onto the medication cart. LPN #1 retrieved the medication, crushed it, and continued to administer it to Resident #2. After the medication had been administered to Resident #2 and the [DEVICE] flushed, LPN #1 without donning gloves, touched the tip of the enteral pump tubing and allowed it to drag over the bed linens prior to reinserting the tip back into the [DEVICE] port. LPN #1 further failed to clean/sanitize the residue left on the barrel of the catheter tip syringe, washed her hands without drying them, and turned off the faucet without a barrier. Due to the LPN #1's work schedule, she was unavailable for interview on 9/7/11. On 9/7/11 at 2:30 PM a review of the facility policy titled Nasogastric Gastrostomy Tube Feeding revealed in Procedure #5 Make sure that tip of both tubings are covered or placed in a way so as not to contaminate the tip of either. Also, review of the facility policy titled Hand Washing revealed in Procedure # 4 Dry hands well with paper towel, and Procedure #5 Turn off faucet or spray nozzle with dry paper towel. | 2015-10-01 |
| 8914 | 8914 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2011-09-07 | 371 | E | 0 | 1 | O94H11 | On the days of the survey, based on observation and interview, the facility failed to store and prepare food under sanitary conditions as evidenced by dented cans in the dry storage room, meat thawing over bread, hood filters covered with dust, and staff unable to demonstrate how to properly calibrate a thermometer. The findings included: Observations on 9/6/11 at approximately 11:35am revealed, 2 - #10 cans of diced pears, 3 - #10 cans of sliced apples and 1- 8 ounce can of Ensure in the dry storage room that were dented. In the walk-in cooler, a ham was observed thawing on the bottom shelf. Under the ham was a case of loaf bread. The filters for the hood had an accumulation of grease and dust. Observation on 9/7/11 at approximately 11:50am revealed staff taking the temperature of the food with a thermometer with a scale of 50 to 550 degrees Fahrenheit (F). There was no notation on the thermometer for a temperature below 50 degrees F. When cook #1 was asked to calibrate the thermometer, she placed the thermometer in an ice bath. When asked what temperature she was to calibrate the thermometer to she stated 0 degrees. The surveyor then asked the Kitchen Manager and the Certified Dietary Manager (CDM) what temperature the thermometer was to be calibrated to - both stated 0 degrees. The surveyor then asked all three present to show where on the thermometer you would read 0 degrees. All acknowledged the thermometer could not read 0 degrees. Further interview with the CDM indicated that the facility did not have policy/procedure for how to calibrate a thermometer or to what temperature the thermometer should be calibrated (32 degrees F). Further observations on 9/7/11 at approximately 12:10pm with the Kitchen Manager and CDM revealed the dented cans were still in the dry storage room and the filters for the hood still had an accumulation of grease and dust. Interview with the CDM at that time indicated that nothing should be placed under meat when it is thawing. In addition, the filters for the hood are cleaned month… | 2015-10-01 |
| 4184 | 4184 | SPRENGER HEALTH CARE OF PORT ROYAL | 425413 | 1810 RICHMOND AVENUE | PORT ROYAL | SC | 29935 | 2018-08-28 | 689 | D | 0 | 1 | K0MQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the staff used a gait belt to transfer one of eight sampled residents (Resident (R) 7). Findings include: Review of an undated Nurse and State tested Nursing Assistant (STNA) training document indicated: Every resident will have a required method for all transfers- refer to (the) Kardex for details. Do not lift (a resident) from under (their) arm pits, pull up on (their) arms, (or) bear hug (a) resident to move them. Review of R7's admission documentation indicated the facility admitted the resident on 05/25/18 with [DIAGNOSES REDACTED]. Review of R7's Nursing Admission Assessment, dated 05/25/18, indicated R7 was, Able to sit in wheelchair. Requires total assist with all ADLs. Review of the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 06/01/18 specified under Section C: Cognitive Patterns, that R7 had a Brief Interview for Mental Status (BIMS) score of one out of 15, which indicated he had severe cognitive impairment. Section G: Functional Status, indicated R7 required total assistance of two or more persons for transfers. Review of R7's undated care plans indicated the staff developed a Focus statement that read: ADLs (Activities of Daily Living) self-care deficit R/T (related to) [MEDICAL CONDITION], major [MEDICAL CONDITION] and OA ([MEDICAL CONDITION]). Interventions included, Transfers -two person assist for safety. Review of a hospice note, dated 07/20/18, indicated the resident had begun to exhibit, Contracture(s) of arms and legs. arms and legs drawn up in fetal position. Will not straighten without assist. Observation on 08/28/18 at 8:15 AM in R7's room revealed Certified Nurse Aide (CNA)1 used the call light to request assistance, and then moved the… | 2020-09-01 |
| 4185 | 4185 | SPRENGER HEALTH CARE OF PORT ROYAL | 425413 | 1810 RICHMOND AVENUE | PORT ROYAL | SC | 29935 | 2019-09-19 | 565 | E | 0 | 1 | 85QU11 | Based on interviews and document review, the facility failed to ensure the staff acknowledged and acted promptly upon the grievances voiced by the Resident Council related to the staffs' slow response time to call lights as indicated by 10 of 10 residents in attendance during the Resident Council Interview (Residents (R)1, R3, R4, R5, R6, R7, R8, R10, R11, and R15). The findings included: Review of the monthly Resident Council Meeting Minutes dated 12/20/18 through 08/28/19 revealed the following statements of concern regarding the issue of the Certified Nursing Assistants (CNAs) not answering the residents' call lights in a timely manner: On 12/20/18 - Two complaints of the CNA taking too long to answer the call button. On 01/30/19 - A couple of complaints about how long it takes the CNAs to answer the call button, especially at night. On 03/27/19 - A few residents say it takes too long for call buttons to be answered. On 04/30/19 - Complaints about call button not being answered. On 06/26/19 - Complained of CNAs and (the) RN (Registered Nurse) on night shift taking too long to answer the call button. On 07/31/19 - One resident said she rang her call button at 4:50 AM and it was 6:30 AM before anyone came to help her. She had needed to go to the restroom and soiled herself while waiting. One resident said she waited an hour and a half for someone to put her on the bedpan and another hour to get off when she finished. One resident has a family member stay every night because the CNAs do not answer the call buttons in a timely manner. On 08/28/19 - Residents continued to express concern about night time aides and how long it takes for their call buttons to be answered. During the Resident Council Interview held on 09/18/19 at 10:30 AM, the 10 residents that attended the meeting indicated additional facility staff is needed during the night shift to ensure residents call lights are answered in a timely manner by the staff. The residents did not remember ever receiving an update regarding any concerns they voiced to… | 2020-09-01 |
| 4186 | 4186 | SPRENGER HEALTH CARE OF PORT ROYAL | 425413 | 1810 RICHMOND AVENUE | PORT ROYAL | SC | 29935 | 2019-09-19 | 679 | D | 0 | 1 | 85QU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person-centered program of activities and associated care plan designed to meet the recreational interests and socialization needs for one resident on contact isolation precautions out of 16 residents selected for review (Resident (R)2). The findings included: Review of R2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An admission to the hospital occurred on 08/24/19 due to an abdominal wall abscess resulting in an additional abdominal surgery. R2 returned to the facility on [DATE] with orders for wound care for her abdominal incision, orders for physical and occupational therapy, and orders for contact isolation precautions due to a new [DIAGNOSES REDACTED]. diff) toxin infection (a communicable infection of the intestines). Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated she had no cognitive impairment. The MDS assessment indicated it was somewhat important to the resident that she be able to, go outside to get fresh air when the weather is good and to participate in religious services or practices. During an interview on 09/16/19 at 11:00 AM, R2 stated her desire to get stronger so she could return home. R2 was aware that she was on contact isolation precautions due to her infection and that she had to stay confined to her room. R2 stated the physical and occupational therapists come to her room to provide therapy, and when she was not busy with therapy, she worked on her word puzzle book on her bedside table. During a subsequent interview on 09/17/19 at 10:30 AM, when asked if a staff member had offered her activities that she could do in her room, R2 stated, No, and then added that she was interested in receiving additional activities because she d… | 2020-09-01 |
| 4187 | 4187 | SPRENGER HEALTH CARE OF PORT ROYAL | 425413 | 1810 RICHMOND AVENUE | PORT ROYAL | SC | 29935 | 2019-09-19 | 880 | D | 0 | 1 | 85QU11 | Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure staff used standard precautions to prevent the potential spread of infection during the preparation and administration of medications for two of six residents observed during medication pass (Residents (R)5 and R18). The findings included: 1. Observation on 09/18/19 at 7:42 AM revealed Registered Nurse (RN)1 used an alcohol-based hand rub to cleanse her hands. Using her bare hands, the RN then picked up a potentially contaminated bottle of medication for R5 and dispensed two tablets from the medication bottle into her ungloved right hand. The RN then placed the tablets in a medication cup, and proceeded to administer the medication to R5. 2. Observation on 09/18/19 at 8:11 AM revealed RN1 used an alcohol-based hand rub to cleanse her hands. Using her bare hands, the RN then picked up a potentially contaminated bottle of medication for R18, dispensed one tablet from medication bottle into her ungloved right hand and placed the tablet in a medication cup. RN1 then popped out two tablets from two potentially contaminated medication blister packs into her ungloved right hand and then placed these two tablets into the medication cup. Continued observation revealed RN1 then went into R18's room and handed the resident the medication cup. When R18 dropped one of the tablets onto the bed linen, RN1 picked up the tablet with her ungloved hand and gave it back to the resident to take. During an interview on 09/18/19 at 8:20 AM, when asked about the appropriate method for medication administration, RN1 stated, Medication should be placed directly in medication cup, and not be handled by bare hands. RN1 then stated, I should have disposed of the pills once I touched them. During an interview on 09/18/19 at 8:45 AM, when asked about the correct process for dispensing residents' medications, Licensed Practical Nurse (LPN)1 responded, If the resident's medications are in liquid or in pill form, it is placed directly i… | 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 |
| 2000 | 2000 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 580 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled,Transfer or Discharge, Emergency, the facility failed to ensure the physician was notified of a change in condition/decline and transfer to the hospital for Resident #13 for 1 of 2 residents reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 2/22/2018 at approximately 2:39 PM of the nurses notes dated 2/1/2018 reads, Resident is alert and oriented , unable to get 02 (oxygen) SAT (saturation) above 80%. PRN (as needed) breathing treatment given without effectiveness. Increased 02 to 4 liters per minute (lpm ) not effective either. Resident was sent to the emergency room for evaluation based on history of respiratory distress. Daughter/son was called , states, aware of his/her (parent) is going to the emergency room . Resident took valuables with him/her. No documentation could be found in the medical record to ensure the physician was notified of a change/decline in status for Resident #13 or that he/she was transferred to the emergency room for evaluation. Resident #13 was admitted on [DATE] to the hospital. During an interview on 2/22/2018 at approximately 3:48 PM with the Registered Nurse (RN) Unit Manager, he/she confirmed there was no documentation to ensure the physician was notified of the change in condition prior to transferring Resident #13 to the hospital The nurse manager went on to say that the nurse did notify the physician even though it is not documented in the medical record. Review on 2/22/2018 at approximately 5:00 PM of the facility policy titled, Transfer or discharge, Emergency, under Policy Statement, Emergency transfers or discharges may be necessary to protect the health and or well being of the residents. Under, Policy Interpretation and Implementation, number 4 states, Should it be necessary to make an emergency transfer or discharge to a hospital or other related insti… | 2020-09-01 |
| 2001 | 2001 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 582 | B | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure that each resident received proper notice of expiration of Medicare benefits for 1 of 3 residents reviewed for beneficiary protection notification. The findings included: Record review on [DATE] at 4:07PM proved that Resident #80 was not given a 48 hour notice of when his/her Medicare benefits will expire. The Notice of Medicare Non-Coverage form stated that services will end on [DATE], however the Resident signed the form on [DATE]. The Director of Nursing (DON) confirmed that the Resident was not notified 48 hours before Medicare benefits expired. | 2020-09-01 |
| 2002 | 2002 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 623 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Facility - Initiated Transfer/Discharges, the facility failed to ensure the Personal Representative for Resident #13 was notified in writing in a language he/she could understand of the reason for the transfer to the hospital. The facility further failed to ensure Resident #13's Personal Representative received the notice of transfer prior to the transfer for 1 of 3 residents reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 2/22/2018 at approximately 2:39 PM of the nurses notes dated 2/1/2018 reads, Resident is alert and oriented , unable to get 02 (oxygen) SATs (saturation) above 80%. PRN (as needed) breathing treatment given without effectiveness. Increased 02 to 4 liters per minute (lpm ) not effective either. Resident was sent to the emergency room for evaluation based on history of respiratory distress. Daughter/son was called , states, aware of his/her (parent) is going to the emergency room . Resident took valuables with him/her. No documentation could be found in the medical record for Resident #13 to ensure the Personal Representative was notified in writing, in a language he/she could understand of the reason for the transfer to the hospital prior to the transfer to the hospital. During an interview on 2/22/2018 at approximately 3:48 PM with the Registered Nurse (RN) #1, Unit Manager, he/she confirmed that there was no documentation in Resident #13's medical record to ensure the Personal Representative was notified in writing and in a language he/she could understand of the reason of the transfer and prior to the transfer to the hospital. Review on 2/22/2018 at approximately 5:20 PM of the facility policy titled, Facility - Initiated Transfers/Discharges, states under Emergency Transfers, When a resident is temporarily transferred on an emergency basis to an acute care facility, not… | 2020-09-01 |
| 2003 | 2003 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 657 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Fall Safety Program, Falls and Fall Risk, Managing, and Falls Risk Assessment, the facility failed to ensure the Plan of Care for Resident #25 was reviewed and revised with interventions to prevent falls and/or to reduce the risk for falls for 1 of 3 residents reviewed for Accidents. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review on 2/21/2018 at approximately 3:42 PM of a form titled, Falls Risk Evaluation, completed on admission is scored 22 and states any score greater than 10 is high risk for falls and/or falls with injury. The evaluation indicated that Resident #25 had fallen 6 times in the last 90 days prior to admission and was high risk for falls. Review on 2/21/2018 at approximately 4:25 PM of the facility policy titled, Falls Risk Assessment, under, Policy Interpretation and Implementation, number 1 states, The nursing staff will review a resident's record for evidence of previous falls in the last 90 days, and recurrent or periodic bouts of falling over time. A Fall Evaluation will be completed on admission. A score of 10 or higher, start intervention. Number 9 states, A resident who falls will be placed on the, Falling Star Program. The Plan of Care for Resident #25 did not include the Falling Star Program and was not reviewed and revised with interventions, after a fall, to help prevent falls or to reduce the risk of falling. Review on 2/21/2018 at approximately 4:25 PM of the Plan of Care dated 2/2/2018 for Resident #25 revealed the basic interventions to reduce or prevent falls such as, bed in low position and frequently used personal items within reach were not on the plan of care. Further review on 2/21/2018 at approximately 4:25 PM of the Plan of Care for Resident #25 indicated that the Plan of Care has not been reviewed and revised after a fall in the facility. Review on 2/21/2018 at approximately 4:25 P… | 2020-09-01 |
| 2004 | 2004 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 684 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Head Injury Policy, the facility failed to ensure the Neurological checks, ordered by the Physician for Resident #25, were completed timely and accurately for 1 of 3 residents reviewed for Accidents. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review on 2/21/2018 at approximately 3:42 PM of an Incident Report of a fall for Resident #25 revealed, a fall in the bathroom no apparent injuries were documented. Upon assessment Resident #25 not sure if he/she had hit their head. The physician ordered neurological checks. The neurological checks were implemented timely for Resident #25. Review on 2/21/2018 at approximately 3:45 PM of the form titled, Neurological Flow Sheet, revealed documentation started on 2/12/2018 at 8:50 AM. The directions were as follows: Vital signs and Neurological checks, every 15 minutes for 1 hour, every 30 minutes for 1 hour and 1 hour for 4 hours then every 4 hours for 24 hours. The form also stated, progress along this time schedule ONLY if the vital signs are stable. Further review on 2/21/2018 at approximately 3:48 PM of the Neurological Flow Sheet, revealed the every 15 minute checks as completed accurately when started at 8:50 AM. Then the 30 minute intervals for 1 hour were not documented on the form. The 1 hour intervals for 4 hours were not documented correctly on the form and the every 4 hour documentation for 24 hours was not completed as indicated by the directions on the form. Review on 2/21/2018 at approximately 4:00 PM of the facility policy titled, Head Injury Policy, states under number 5. If Resident has hit their head: Check vital signs, level of consciousness, hand grasp, speech, movement and pupil reaction; every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for 4 hours and every 4 hours for 18 hours for a total of 24 hours. Number 6 states, These assessments must be co… | 2020-09-01 |
| 2005 | 2005 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 689 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Fall Safety Program, Falls and Fall Risk, Managing, and Falls Risk Assessment, the facility failed to implement interventions for Resident #25 to prevent falls and or to reduce the risk for falls for 1 of 3 residents reviewed for Accidents. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review on 2/21/2018 at approximately 3:42 PM of a form titled, Falls Risk Evaluation, completed on admission is scored 22 and states any score greater than 10 is high risk for falls and or falls with injury. The evaluation indicated that Resident #25 had fallen 6 times in the last 90 days prior to admission and was high risk for falls. Review on 2/21/2018 at approximately 4:25 PM of the facility policy titled, Falls Risk Assessment, under, Policy Interpretation and Implementation, number 1 states, The nursing staff will review a resident's record for evidence of previous falls in the last 90 days, and recurrent or periodic bouts of falling over time. A Fall Evaluation will be completed on admission. A score of 10 or higher, start intervention. Number 9 states, A resident who falls will be placed on the, Falling Star Program. The Plan of Care for Resident #25 did not include the Falling Star Program and was not reviewed and revised with interventions, after a fall, to help prevent falls or to reduce the risk of falling. Review on 2/21/2018 at approximately 4:25 PM of the Plan of Care dated 2/2/2018 for Resident #25 revealed the basic interventions to reduce or prevent falls such as, bed in low position and frequently used personal items within reach were not on the plan of care. Further review on 2/21/2018 at approximately 4:25 PM of the Plan of Care for Resident #25 indicated that the Plan of Care has not been reviewed and revised after a fall in the facility. Review on 2/21/2018 at approximately 4:25 PM of the facility, Fall Safety Program, stat… | 2020-09-01 |
| 2006 | 2006 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 758 | E | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide nonpharmacological interventions prior to the administration of as needed pain (PRN) medication for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #130 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 2/21/18 at approximately 1PM revealed that staff did not attempt nonpharmacological interventions for Resident #130. The Assistant Director of Nursing (ADON) was interviewed on 2/21/18 at 3:50PM and asked of the expectation of nurses before giving PRN pain medications. ADON stated I would expect them to assess the resident first. They are also supposed to try things such as giving water, turning on music and changing position before they pop something down their throats. ADON was then asked if nurses were expected to document the nonpharmacological interventions and stated that there was a special form that the facility used. ADON attempted to show surveyor the form, but was unable to gain access to the form. Registered Nurse (RN) #1 was interviewed and asked if nonpharmacological interventions were done for as needed pain medication, and stated that they weren't. | 2020-09-01 |
| 2007 | 2007 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 761 | D | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure that it was free of expired medications in 1 of 1 treatment carts. The findings include: On 2/22/18 at approximately 10:44 AM inspection of the treatment cart revealed the following: -9 PDI SaniHands (70 percent alcohol) Pads, expired 12/17 (12/31/17) in the top drawer -1 Derma Pak-Its ([MEDICATION NAME]) Strip, expired 4/2017 (4/30/17) in the 4th drawer -1 Derma Pak-Its ([MEDICATION NAME]) Strip, expired 2/2017 (2/28/17) in the 4th drawer On 2/22/18 at approximately 10:55 AM this finding was verified by RN (Registered Nurse) # 4 and RN # 1. | 2020-09-01 |
| 2008 | 2008 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 812 | E | 0 | 1 | GHY311 | Based on observations, interview and review of the facility policy titled, Food Storage, the facility failed to ensure opened and unused foods are dated with the open date prior to storing in 1 of 1 dry storage rooms and in 1 of 2 reach in freezers. The findings included: Observations on 2/20/2018 at approximately 11:30 AM during initial tour of the kitchen revealed 1 large plastic container of barbeque sauce on a shelf in the dry storage room that had been opened and not dated with the open date. Further observation on 2/22/2018 at approximately 11:30 AM during the initial tour of the kitchen revealed waffles that had been opened and not dated with the open date in 1 of 2 reach in freezers. During an interview on 2/20/2018 at approximately 11:30 AM the Dietary Manager confirmed the findings. A random observation, during the lunch meal service on 2/22/2018 at approximately 11:50 AM the Dietary Manager, removed a carton of milk from the refrigerator and opened it and put a hand held thermometer in to get the temperature and then placed it back in the refrigerator for resident use. The Dietary Manager stated, there is no need to waste it. Review on 2/22/2018 at approximately 3:00 PM of the facility policy titled, Food Storage, states under Policy, Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free of contaminants. Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Under Procedure, number 13. states Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Number 15c. under Frozen Foods: states, All foods should be covered, labeled and dated. | 2020-09-01 |
| 2009 | 2009 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 814 | D | 0 | 1 | GHY311 | Based on observations, interview and review of the facility policy titled, Dumpster: Debris Removal and Old Grease Removal, the facility failed to ensure bagged trash was put inside the dumpster and not on the outside surrounding the dumpster for 1 of 1 dumpsters observed. The facility further failed to ensure grease was contained in grease bins and not puddled outside the bin on the solid surface in 2 of 2 grease bins observed. The findings included: An observation on 2/22/2018 at approximately 11:30 AM of the outside dumpster revealed bagged trash placed on the surface outside the dumpster and not inside the dumpster. Further observation on 2/22/2018 at approximately 11:30 AM revealed 2 grease bins with grease puddled on the outside of the bin on the solid surface. An interview on 2/22/2018 at approximately 11:30 AM with the Dietary Manager confirmed the findings. Review on 2/22/2018 at approximately 3:00 PM of the facility policy titled, Dumpster: Debris Removal, states, Number 1. Debris will be inserted in the compactor as needed. No debris will be left on dock. Number 3 states, Loading dock and dumpster/compactor area will be maintained by Food Service department twice daily. Review on 2/22/2018 at approximately 3:00 PM of the facility policy titled, Old Grease Removal, states, Number 1. Grease from fryers will be discarded in above ground bins off the loading dock on an as used basis, Number 3 states, Area to be kept clean by Food Service Department, | 2020-09-01 |
| 2010 | 2010 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 880 | E | 0 | 1 | GHY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Laundry and Bedding, Soiled, Personal Protective Equipment, Legionella Water Management Program, Legionella Surveillance and Detection, and the Water Management Team the facility failed to ensure PPE, (Personal Protective Equipment) was provided in the laundry department and failed to remove a mop from a mop bucket with dirty water in 1 of 1 laundry rooms. The facility further failed to ensure soiled and clean laundry were handled separately in two areas in 1 of 1 laundry rooms. The facility additionally failed to ensure a water fountain was cleaned after testing positive for Legionella Bacteria and retesting of the cleaned/treated areas was completed in a timely manner for 6 of 6 areas previously tested positive for Legionella Bacteria. Dietary staff failed to wash hands prior to handling food during the temping process in 1 of 1 satellite kitchens. The findings included: An observation on 2/22/2018 at approximately 9:46 AM of the laundry room revealed no PPE in the laundry to use while sorting soiled laundry. A second observation on 2/22/2018 at approximately 9:46 AM of the laundry room revealed no distinction between the clean and dirty area of the laundry room. A random observation on 2/22/2018 at approximately 9:40 PM of the laundry area revealed a mop submerged in a container of dirty water used for mopping the floor. An interview on 2/22/2018 at approximately 9:53 AM with a Laundry Worker and the Housekeeping Supervisor confirmed that no PPE was in the laundry room and that there was no distinction between the clean and dirty area of the laundry room. During the interview on 2/22/2018 at approximately 9:53 AM with the Laundry Worker and the Housekeeping Supervisor confirmed the mop in a dirty container of water was in the laundry area. Review on 2/22/2018 at approximately 10:00 AM of the facility policy titled, Personal Protective Equipment, under Policy Statem… | 2020-09-01 |
| 2011 | 2011 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-02-22 | 908 | D | 0 | 1 | GHY311 | Based on observation, interview and review of the facility policy titled, Maintenance Service, the facility failed to ensure an excessive amount of lint was removed from behind 2 of 2 clothes dryers. The findings included: An observation on 2/22/2018 at approximately 9:46 AM of the laundry room revealed an excessive amount of lint on the backs of the dryers and on the floor around the vents. An interview on 2/22/2018 at approximately 9:53 with the Laundry worker and the Housekeeping Supervisor confirmed the excessive amount of lint behind the clothes dryers. Review on 2/22/2018 at approximately 10:35 PM of the facility policy titled, Maintenance Service, states, under Policy Statement, Maintenance service shall be provided to all areas of the building, ground, and equipment. The Policy Interpretation and Implementation, number 1. states, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment is in safe and operable manner at all times. Number 2, states, Functions of maintenance personnel include, but are not limited to: (i.) Providing routinely scheduled maintenance service to all areas. Number 3. states, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe operable manner. | 2020-09-01 |
| 2012 | 2012 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-11-01 | 552 | D | 0 | 1 | PKPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Residents Bill of Rights. the facility failed to ensure Resident #14 was afforded the right to make his/her own health care decision to receive or refuse the Influenza Vaccine for this current flu season. Resident #14 was not deemed unable to make own health care decisions for 1 of 6 residents reviewed for the Influenza Vaccine. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Resident #14 has a BIMS (Brief Interview for Mental Status) of 11 out of a possible 15 on 9/24/2018. Review on 11/1/2018 at approximately 10:45 AM of the medical record for Resident #14 revealed a form titled, Informed Consent for Influenza Vaccine, dated 9/20/2018 revealed a telephone consent provided by the Power of Attorney for Resident #14. Further review on 11/1/2018 at 10:45 AM of the medical record for Resident #14 revealed a form titled, Do Not Resuscitate, Consent Cognitive Resident, under Physician's Order states, Resident has the ability to understand and appreciate the nature and consequences of an order not to resuscitate, including the benefits and disadvantages of such an order, and to reach an informed decision regarding this order, The DNR was signed by the resident due to the fact that Resident #14 was not deemed unable to make his/her own health care decisions. An interview on 11/1/2018 at approximately 11:00 AM with the DON (Director of Nursing) confirmed that Resident #14 was not offered the right to make his/her own health care decision related to receiving or refusing the Influenza Vaccination for the current flu season. Review on 11/1/2018 at approximately 11:20 AM of the facility's Residents Bill of Rights, states, The resident has the right to a dignified existence, self-determination and communications with a access to persons in and outside the facility. The facility will protect the rights of each resident. Number 2 under, Resident… | 2020-09-01 |
| 2013 | 2013 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-11-01 | 572 | D | 0 | 1 | PKPJ11 | Based on interview and record review, the facility failed to provide information to residents related to residents rights. The facility failed to provide ongoing communication related to resident rights for 4 of 7 residents attending Group Interview. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if staff talks about and reviews the rights of residents in the facility during the Resident Council meetings. The 4 active participants were unable to answer this question and indicated that this was not done. Review of the Resident Council meeting minutes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed no documentation to indicate staff provided ongoing communication to residents about their rights. There was no documentation to indicate resident rights were discussed during any of the meetings. During an interview 11/1/18 at approximately 2:50 PM, the Activity Director confirmed that there was no documentation to indicate ongoing communication to residents about their rights and confirmed that he/she had not discussed resident rights during the Resident Council Meetings. | 2020-09-01 |
| 2014 | 2014 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-11-01 | 574 | C | 0 | 1 | PKPJ11 | Based on observation and interview, the facility failed to ensure residents were provided and were aware of contact information for all resident advocacy groups. The facility failed to post contact information that was readily accessible to residents and visitors in the facility. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the Ombudsman's contact information is posted. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated this information was posted on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus. Further observations indicated this information was posted high on the wall and would not be visible and readily accessible to residents in wheel chairs. During an interview on 11/1/18, the Director of Nursing confirmed this finding and informed the surveyor this posting would be lowered on the wall. | 2020-09-01 |
| 2015 | 2015 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2018-11-01 | 577 | C | 0 | 1 | PKPJ11 | Based on observation and interview, the facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents and that the notice of the availability of the reports was posted in areas of the facility that are prominent and accessible to the public. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the latest State survey inspection report was located. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the inspection report was located in a holder on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus and was not frequented by all residents and visitors. Observation of the main lobby of the facility revealed no posting or signage indicating where this report was located. Further observation revealed a small sign listing the location was taped to a post at the nurse's station. During an interview on 11/1/18, the Director of Nursing confirmed this finding. | 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 );