Presbyterian Home Of SC - Foothills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interviews, the facility failed to ensure that the arbitration agreement signed by all facility residents, with a current census of 19 residents, provided for the selection of a venue that was convenient to both parties. Additional information documented in the admission Agreement revealed a stipulation related to the South Carolina Code of Laws that was not further clarified in this signed contract. Specifically, the facility failed to ensure that a neutral venue available to both parties was documented within the arbitration agreement and that potential Arbitration Agreement exempts existed within this form. The exclusion of providing a mutually agreed upon neutral venue location, and providing additional information about a South Carolina Arbitration Agreement exemption placed facility residents and families at an unknown disadvantage to potential future disputes. Findings include:Review of the facility provided admission Agreement, dated August 2024, revealed a Header that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility policy review, review of the Food and Drug Administration (FDA) guidelines and review of Manufacturer's Instructions for Use (MIFU), the facility failed to ensure bed frames, electrical components, and bed rails if present, were inspected and maintained by MIFU for the 19 current residents in the facility. This deficient practice has the potential for bed malfunction, contributing to possible resident injury.Findings include:Review of the facility provided Med [NAME] User Manual, page 13 Maintenance provided by the facility revealed: Maintenance and Service, Notice: Recommended to perform preventative maintenance every 12 months for best performance. 1. Inspect the frame for weld cracks or tears. 2. Check that all bolts, pins and fasteners are still in working order. 3. Perform functional test on the frame. 4. Inspect the casters for wear and tear. In a column titled Preventative Maintenance Inspection was a list of items: Inspect bed frame for cracks, tears, or bending,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternatives were attempted prior to the use of bed rails for 4 of 4 residents (Resident (R)22, R24, R40, and R41) reviewed for bed rails out of a total sample of 13. This failure had the potential to increase accidental entrapment or injury when an alternate assistive device may have been effective.Findings include:Review of the undated facility policy titled Proper Use of Side Rails revealed, .The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines . 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. 6. Less restrictive interventions that will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 resident (Resident (R) 32) of 13 residents in the sample reviewed for MDS accuracy. Specifically, R32's MDS failed to identify the correct discharge location at the end of the resident's stay. This failure created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care. Findings include:Review of the facility's policy titled, MDS 3.0 Completion dated 10/01/24 revealed, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Discharge Assessment-completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD. Review of R32's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 of 3 residents (Resident (R)35) reviewed for respiratory services, received oxygen as ordered by the physician. This failure placed the resident at risk of receiving insufficient oxygen to meet the assessed respiratory need.Findings include:Review of the facility's undated policy titled, Oxygen Administration stated, . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .Review of R35's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R35 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses including but not limited to, acute respiratory failure with hypoxia.Review of R35's EMR under the Orders tab revealed a physician order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that 1 of 3 residents (Resident (R)24) reviewed, that signed an arbitration agreement, were provided with an explanation of the binding agreement in a form and manner that they or their representative understood. The failures to ensure residents or their representatives were properly and clearly informed of the signed binding arbitration agreement could affect the ability for residents and families to be properly informed of the potential implication of the binding agreement on decisions and choices about important aspects of residents' health, safety, and welfare. Findings include:Review of R24's Arbitration Agreement located in the electronic medical record (EMR) under the Miscellaneous tab indicated the resident and family member (FM)1 had signed and initialed the facility Arbitration Agreement on 02/04/26. Review of R24's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated no cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, and interviews, the facility failed to timely report an allegation of abuse for 1 of 1 residents (R)76, reviewed for abuse. Not reporting timely had the potential to cause further potential abuse. Findings include: Review of the facility's undated policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals recorded under the policy, All suspected violations .of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. R76 was admitted to the facility on [DATE] with diagnoses that include, but not limited to multiple fractured ribs left side, atrial fibrillation, pleural effusion, congestive heart failure and hypertension. Record review of R76's Minimum Data Set (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility policy, report review and interview, the facility failed to complete and submit 2 of 3 resident Minimum Data Sheet (MDS) assessments timely. Findings include: Review of the undated facility policy titled, Resident Assessment Using the Minimum Data Set (MDS), revealed under the policy, Every resident will be assessed using the MDS according to guidelines set forth in the Resident Assessment Instrument (RAI) manual. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the MDS 3.0 Missing OBRA Assessment Report dated 01/09/2025 revealed the facility had 3 resident assessments that were not submitted to CMS. Review of the MDS 3.0 Nursing Home Validation Report dated 01/14/2025 at 11:12 AM revealed the same 3 residents that were missing were submitted after the Missing OBRA Assessment Report was given to the Administrator. An interview with the MDS Nurse on 01/14/2025 at 3:25 PM revealed that the 3 resident assessment were not submitted and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure a resident's end of life wishes and physician's orders were correctly documented throughout the medical record resulting in the potential that one resident's wishes (Resident (R) 122) out of a total sample of 13 residents would not be honored in the event of a life-threatening emergency. Findings include: Review of the facility's undated Advance Directives policy, indicated .information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record, on the MAR, TAR (Treatment Administration Record), and care plan . The assigned Nurse will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Nursing will mark the residents chart . Review of the facility's undated Do Not Resuscitate Order Policy Statement indicated Our facility will not use cardiopulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.