Greenville Post Acute

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to notify Resident (R)1's physician of elevated blood pressures for 1 of 1 resident, reviewed for notification of changes. Findings Include:Review of the facility policy titled Change In a Resident's Condition or Status with a complete revision date of February 2021 states, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care. billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . 2. [...]

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to obtain and administer missing Lacosamide, a seizure medication, for Resident (R)2, resulting in the resident not receiving 11 doses of the medication from 1/7-1/13, for 1 of 1 resident reviewed. Findings Include: Review of the facility policy titled, Adverse Consequences and Medication Errors, with a revision date of June 2025 revealed, Policy Statement: The interdisciplinary team monitors medication usage to prevent and detect medication - related problems such as adverse drug reactions (ADRs) and side effects. Medication Errors: 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principals of the professional(s) providing services. 2. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that menus were followed in regard to serving sizes. This had the potential to affect 120 of 124 residents who consumed meals from the facility's kitchen and placed them at nutritional risk. The facility identified four resident who were nothing by mouth (NPO).

Inspectors wroteBased on observation, interview, and test tray sample, the facility failed to provide food that was palatable and at the proper temperature. This had the potential to affect 120 of 124 residents who consumed food from the kitchen and for them to be at nutritional risk. The facility identified four residents who were nothing by mouth. (NPO).

Inspectors wroteBased on record review, interview, observation, and review of facility policy, the facility failed to allow immediate family or other relatives the right to visit at any time for one (Resident (R) 122), reviewed for visitation of 31 sample residents. This had the potential for the resident to experience a decreased quality of life.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of staff to resident verbal abuse for one (Resident (R) 89) reviewed for abuse was reported to the state agency (SA) within two hours of knowledge of the alleged verbal abuse. The failure to timely report allegations of abuse put the resident at risk for further abuse.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of staff to resident verbal abuse for one (Resident (R)89) reviewed for abuse out of a total of 31 sampled, was thoroughly investigated. The failure to thoroughly investigate allegations of abuse had the potential for further abuse to the resident. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date 04/21, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to . verbal abuse. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a written transfer notice that contained all required information was provided to three of three residents and/or their representative (Resident (R) 87, R113, and R83) reviewed for facility initiated emergent hospital transfer out of 31 sample residents. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, review of maintenance documentation, and review of facility policy, the facility failed to ensure one siderail was securely attached to the bed for one Resident (R)33) of one resident reviewed for side rails, which resulted in a fall, which required hospitalization out of a sample of 31 residents. After the fall, R33 developed a hematoma and pain to the right leg. This had the potential for other residents to have side rail safety issues that had the potential for residents to fall or sustain injuries.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that facility's Binding Arbitration Agreement (BAA) was explained to residents in a manner that they understood for three out of three (Residents (R)68, R117, and R276) out of a total sample of 31 residents. The facility further failed to ensure the BAA informed residents and/or representative they had the right to rescind the agreement within 30 days. This failure placed the 122 residents at risk of signing an agreement they did not understand.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to implement the Care Plan by not using the proper number of staff during a mechanical lift/transfer for 1 (Resident (R)19) of 40 residents reviewed for Care Plans. This had the potential to cause an injury to the resident.

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to ensure a potential hazard was secured and not accessible to vulnerable residents. Specifically, scissors were observed on 1 of 2 units and on top of 2 of 2 unattended medication carts.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure the medical necessity of psychotropic medication administration for 1 out of 5 residents reviewed for Psychotropic Medication Administration. The facility failed to ensure informed consent for the administration of psychotropic medications and failed to track accurate behaviors for Resident (R)102, who was receiving multiple psychiatric medications. A total of 40 residents were reviewed in the sample.

Inspectors wroteBased on record review, observations, staff interviews, review of an on-line drug resource guide (Medline), and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Five errors were observed with a total of 35 opportunities for error, resulting in an 14.2% error rate. The errors involved one Resident (R)47 of eight residents observed for medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure a significant medication error did not occur for one (Resident (R)2) of six residents reviewed for unnecessary medications. Specifically, the facility failed to capture an admission order for an antibiotic and the medication was never administered as ordered.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure its Infection Prevention and Control Program (IPCP) included adequate surveillance for COVID-19 monitoring upon entrance to the facility. This failure had the potential to increase the spread of infections to 122 residents within the facility.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to maintain dignity, specifically by leaving a urinary catheter bag uncovered for one of three residents (Resident (R) 216) sampled for dignity.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a quarterly review assessment in a timely manner for one of 29 residents sampled (Resident (R) 2).

Inspectors wroteBased on review of facility policy and procedure, record review, observations, and resident and staff interviews, the facility failed to ensure one of five residents (Resident (R) 57) reviewed for Activities of Daily Living (ADLs) received showers/baths consistently per her plan of care.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to have backup tracheostomy supplies readily available for one of one resident (Resident (R) 5) sampled for tracheostomy care. This failure of not having tracheostomy supplies readily available resulted in an immediate jeopardy due to the increased likelihood to cause serious harm or death in the event R5's airway was compromised. This failure also constituted substandard quality of care. On 11/08/21 at 4:30 PM, the Administrator was notified of an immediate jeopardy (IJ) at F695-J Respiratory Care, the IJ template was provided to him at this time. The immediate jeopardy began on 11/08/21 when the survey team identified that tracheostomy supplies were not readily available for R5. The facility provided an acceptable removal plan on 11/10/21 at 2:15 PM. [...]

Inspectors wroteBased on review of facility policy and procedure, record review, and staff interviews, the facility failed to ensure one of six residents (Resident (R) 96) reviewed for urinary catheter care out of a total sample of 29 residents received timely antibiotic treatment for a urinary tract infection (UTI).