L.M.C.- Extended Care

Based on review of facility policy, record reviews, and interviews the facility failed to complete a thorough investigation for allegations of staff-to-resident abuse for 1 Resident (R)21 of 6 sampled residents reviewed for abuse. Specifically, the facility investigation did not include staff interviews from the unit where the resident resided.Review of a facility policy titled, Standard Policy/Procedure, approved 10/21/22, revealed the section titled, DHEC [Department of Health and Environmental Control] Certification and the facility Administrator shall be notified immediately but not later than 2 hours after alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property are made if the events that cause the allegation involve abuse or result in serious bodily injury.Review of R21's Face Sheet revealed the facility admitted R21 on 11/22/24. According toR21's Face Sheet, the resident had a medical history that included diagnoses of depression, cognitive communication deficit, transient…

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 interview and record review, the facility failed to refer Resident (R)4 for a Preadmission Screening and Resident Review (PASARR) Level II, after the resident received a new diagnosis of a severe mental illness, for 1 of 2 residents reviewed for PASARR.Review of R4's Face Sheet indicated the facility admitted R4 on 09/30/2019. According to the Face Sheet, the R4 had a diagnosis of bipolar disorder, dated 07/30/21. Review of R4's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/25, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated R4 had a diagnosis of bipolar disorder. Review of R4's Care Plan, included a problem statement started 12/12/2023, that indicated the resident had diagnoses of a cardiovascular accident (CVA), bipolar disorder, anxiety, and dementia that required the use of psychotropic/psychoactive medications. Interventions directed staff to administer medications as ordered; approach the resident in a calm,…

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 facility policy, record reviews and interviews, the facility failed to ensure Resident (R)191's medical record included documentation they were offered the pneumonia vaccine for 1 of 5 sampled residents reviewed for immunizations.Review of a facility policy titled, Immunization, dated 05/1123, specified, [Facility Name] will offer the pneumonia immunization at admission if there is no history of prior immunization; and immunize against pneumonia unless medically contraindicated or immunization is refused by the resident or the resident's legal representative. Review of R191's Face Sheet revealed the facility admitted R191on 02/23/24. According to R191's Face Sheet, the resident had a medical history that included diagnoses of dementia and chronic obstructive pulmonary disease. Review of R191's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/25, revealed R191had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Review of R191's Continuity of Care Document,…

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 facility policy, record reviews, and interviews the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 Resident (R)21 of 6 sampled residents reviewed for abuseReview of a facility policy titled, Standard Policy/Procedure, approved 10/21/22, revealed the section titled, DHEC [Department of Health and Environmental Control] Certification and the facility Administrator shall be notified immediately but not later than 2 hours after alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property are made if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R21's Face Sheet revealed the facility admitted R21 on 11/22/24. According toR21's Face Sheet, the resident had a medical history that included diagnoses of depression, cognitive communication deficit, transient ischemic attack, cerebral infarction, and malignant neoplasm of the left breast 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 review of the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)3 was treated with respect and dignity when Licensed Practical Nurse (LPN)2, used profanity in and/or around the resident's presence. Findings include: Review of the facility policy titled Abuse/Neglect/Misappropriation/Elder Abuse, last revised 10/21/22, states: .All staff is expected to be in control of their own behavior, behave professionally and appropriately, and understand how to work with the nursing home population. Any substantiated incident will result in employee discipline, which may include termination from the job. Review of R3's Face Sheet revealed, R3 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, severe with agitation, osteoarthritis, anxiety disorder, type 2 diabetes mellitus with hyperglycemia, and disorientation. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 revealed R3's Brief…

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 observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)178's catheter bag, for 1 of 5 residents reviewed. The deficiency disregarded the resident's privacy, dignity, and respect and had the potential to cause psychosocial harm. Findings include: Review of the facility's policy titled, Standard Policy/Procedure with Subject: Catheterization of Female/Male with an approved by date of 07/13/12, revealed, Procedure- 4. Explain the procedure to the patient. Perform hand hygiene. Maintain the patient's privacy and dignity. Review of R178's Face Sheet revealed R178 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroxysmal atrial fibrillation, depression, chronic combined systolic (congestive) and diastolic (congestive) heart failure, retention of urine, acute respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, 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 record review, facility policy review, and interviews, the facility failed to ensure Resident (R)73 and R96 had a physician's order for the code status of 2 of 5 residents reviewed for Advance Directives. Findings include: Review of the facility's policy titled, Do Not Resuscitate (DNR) with an approved by date of 09/08/23, revealed, Procedure: 1. On admission, the Social Worker will determine the desires of the resident and responsible party related to the DNR status. 2. The Social Worker/Speech Therapist will establish resident cognitive status by completing the BIMs tool. 3. If the resident or his/her legal representative wishes to initiate a DNR order, the Code Status form and Emergency Medical Services DNR order will be initiated. 4. If the resident is not considered their own responsible party and has a BIMS score of =<12, then the responsible party as well as two physician signatures are required to establish DNR status. 5. If the resident is considered competent and has a BIMS score of =>13 then…

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 observations, record review, interviews, and facility policy review, the facility failed to ensure medications were properly stored for Resident (R)73 for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled, Subject: Medication Guidelines with an approved by date of 04/25/23 revealed, Policy: Medications are given per physician's order to treat resident's acute and chronic illness. Handling of Non-Controlled Medication: 28. Residents may self-administer a medication based upon physician order, self-administration assessment completed by nurse and review and approval by the interdisciplinary team which determines appropriateness. Review of the undated facility policy titled, Self-Administration of Medications revealed, A. Policy: The facility shall permit residents who are competent and physically able to self-administer their medications if the following conditions are met: 1. Self-administration of medications by residents is permitted only on the specific written orders…

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 facility policy, record review, observation, and interview, the facility failed to proper store and label respiratory equipment for 3 of 5 residents reviewed for respiratory care, Resident (R)73, R99, R263. Findings include: Review of the facility's policy titled, Subject: Oxygen Therapy Protocol with an approved by date of 05/12/11, revealed, Protocol: 1. The Oxygen Protocol will be initiated on residents by a written order from the physician for any type of oxygen therapy . Routine Oxygen Administration and Documentation: .Documentation will be done by nursing on the Medication Administration Record . Review of R73s Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia and generalized anxiety disorder. Review of R73's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/05/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R73 was…

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 facility policy review, observation, and interview, the facility failed to label/store and ensure medications were not expired for 3 of 4 units observed for medication storage. Findings include: Review of the facility policy titled, Nursing Medication Guidelines dated [DATE], revealed under the policy, Medication labels must be correct and legible, check medications for expiration dates and return to the pharmacy. Review of the facility policy titled, Medication Storage dated 09/20, revealed under the policy, The temperature of the refrigerators containing medication shall be maintained between 36-46 degrees F. On [DATE] at 9:10 AM, an observation of [NAME] Place Unit Medication Room with Registered Nurse (RN)2 revealed the medication refrigerator checklist dated [DATE] had 5 days that the refrigerator temperature was not checked, they were blank. The blank dates were [DATE], [DATE], [DATE], [DATE] and [DATE]. RN2 confirmed the dates were blank. RN2 stated, I was off on some of these dates. I am the one…

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 facility policy review, observation, and interview, the facility failed to ensure staff served meal trays under sanitary conditions to prevent the spread of disease and infection. Findings include: Review of the facility policy dated 12/23/20, titled, Nursing Hand Hygiene: Staff and Residents revealed under the policy, Situations that require staff hygiene; before and after handling food, after performing your own personal hygiene, before and after assisting a resident with meals. Review of the facility policy dated 10/01/97, titled, Nursing Uniforms revealed under the policy, Hair of any length must be neatly trimmed, hair must not contaminate the work environment. During an observation on 06/18/24 at 12:07 PM, Certified Nursing Assistant (CNA)5 was passing meal trays, on the lower number 200 hall. While CNA5 took trays from the food cart, her hair touched the tops of the items on each of the meal trays. This continued for all the meal trays CNA5 delivered to the rooms. CNA5 touched her hair after…

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 facility policy, record review, and interview, the facility failed to ensure Resident (R)20 was free from verbal abuse for 1 of 4 residents reviewed for abuse. Findings include: Review of the facility policy dated 10/21/22 and titled Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities/Obligation to Report revealed under the policy, Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. Examples include threats of harm or saying things to frighten a resident. Review of the facility Customer Service Training, no date, titled, Excellent Customer Service Matters, Internal vs. External revealed under the training, Going above and beyond to ensure customers are happy and satisfied with their products and services. It involves being timely, pleasant, and efficient, and building strong relationships with customers. It also means exceeding…

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 observations, interviews, and record review the facility failed to provide care and services for one resident (R)197 of five residents reviewed for limited range of motion out of the sample of 78 residents. The failure to apply splints to the resident's contractures has the potential for increased contractures and/or pain. Findings include: Review of R197's undated Face Sheet located in R197's electronic medical record (EMR) under the Face Sheet tab, indicated R197 was initially admitted to facility on 01/25/10 with a readmission on [DATE] with diagnoses of persistent vegetative state, anoxic brain damage, and hand contractures. Review of R197's quarterly Minimum Data Set (MDS) located in R197's EMR under the Resident Assessment Instrument (RAI), tab with an Assessment Reference Date (ARD) of 04/20/22, revealed R197's Brief Interview for Mental Status (BIMS) was not attempted due to resident is rarely/never understood. R197 is dependent for all activities of daily living (ADLs). R197, according 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.