Hartsville Convalescent Center

Inspectors wroteBased on facility policy review, facility investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent 1 of 6 (Resident #1) residents reviewed for wandering behaviors from exiting the building without staff supervision. Resident #1 was a vulnerable, cognitively impaired Resident with a history of wandering behaviors and wore a wander guard on his person and on his wheelchair. On 10/28/2024, an order was written to discontinue the wander guard from Resident #1's wheelchair. The facility discontinued Resident #1's wander guard from his wheelchair and from his person. Resident #1 eloped from the facility on 11/27/2024, 29 days after the wander guard was discontinued from his wheelchair and his person. [...]

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by unlabeled and undated food items, failed to maintain 1 of 2 coolers in proper working order to prevent potential cross-contamination to stored food, and failed to keep a temperature log and a thermometer for all personal refrigerators for 4 of 4 (Resident #2, #3, #11, and #42) sampled residents reviewed. The facility had a census of 53.

Inspectors wroteBased on facility policy review, hospital record review, medical record review and interview, the facility failed to provide the resident with a notice of the bed hold policy for 5 (Resident #4, Resident #31, Resident #41, Resident #46 and Resident #155) of 5 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 5 sampled residents (Resident #41 and Resident #47) reviewed.

Inspectors wroteBased on facility policy review, facility fall investigation review, medical record review, and interview the facility failed to implement a comprehensive person-centered care plan intervention for 1 of 8 (Resident #39) sampled residents reviewed for falls.

Inspectors wroteBased on facility policy review, facility fall investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent an accident for 1 of 8 (Resident #39) sampled residents reviewed for accidents.

Inspectors wroteBased on facility policy review, medical record review, and interviews the facility failed to provide evaluation and rational for continued use of a PRN (as needed) anti-anxiety medication for 1 resident (Resident #47) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 53 rooms observed. The facility failed to provide clean equipment for 1 of 53 (Resident #155) sampled residents reviewed.

Inspectors wroteBased on facility documentation review, observation and interview, the facility failed to store food in a safe and sanitary manner as evidenced by unlabeled, undated and expired food in the walk-in refrigerator, walk-in freezer and the kitchen dry bin.

Inspectors wrotewBased on medical record review, facility documentation review and interview, the facility failed to complete a Quarterly (once every 3 months) Minimum Data Set (MDS) assessment for 20 (#2, #5, #7, #9, #11, #12, #13, #14, #17, #20, #21, #74, #76, #124, #126, #224, #225, #230, #231 and #276) of 40 resident Quarterly assessments reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to treat 1 (#229) of 1 resident who required a urinary catheter with dignity related to not covering the resident's catheter drainage bag.

Inspectors wroteBased on medical record review, facility documentation review and interview, the facility failed to complete an Annual Minimum Data Set (MDS) assessment for 1 (#125) of 40 resident assessments reviewed.

Inspectors wroteBased on medical record review and interviews, the facility failed to develop a comprehensive care plan for 1 ( #274)of 40 residents reviewed.

Inspectors wroteBased on facility policy review, facility documentation review and interview, the facility failed to have 8 hours of Registered Nurse (RN) coverage on 11/10/2019 for 1 of 73 days reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection for 4 (#10, #18, #230 and #275) of 6 residents during the noon meal on 1/13/2020.

Inspectors wroteBased on facility policy review, facility documentation review and interview the facility failed to ensure a Registered Nurse (RN) was present in the facility at least 8 hours a day 7 days a week for 38 days from 12-1-17 through 12-10-18 (374 days).

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to have a stop date for 5 residents (#9, #26, #29, #30, and #47) after 14 days for PRN (as needed) antipsychotic and psychotropic medications and failed to monitor side effects and behaviors for 30 residents (#1, #2, #3, #4, #5, #8, #9, #12, #13, #14, #17, #18, #20, #21, #23, #26, #29, #30, #31, #34, #35, #36, #37, #38, #40, #41, #43, #47, #48, #49) of 33 residents reviewed.

Inspectors wroteBased on observation and interview, the facility dietary department failed to dispose of expired food; failed to serve cold food at or less than 41 degrees Fahrenheit (F); failed to maintain equipment and serving utensil in a sanitary manner; and failed to operate the dish machine per manufacturer's recommendation, revealed the dietary department staff did not show competency and skill set to safely carry out the functions of the dietary department in 3 of 6 observations.

Inspectors wroteBased on observation, review of the dish machine manufacturer's recommendation, review of the dish machine operation log, and interview, the facility dietary department failed to dispose of expired food; failed to maintain equipment in a sanitary manner; failed to store serving utensils in a sanitary manner; and failed to operate the dish machine according to the manufacturers recommendation for 3 of 6 dietary department observations.

Inspectors wroteBased on observation and interview, the facility dietary department failed to serve cold food, for resident meals, at or less than 41 degrees Fahrenheit (F) in 1 of 2 meals observed.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to maintain infection control due to staff failing to use Personal Protective Equipment while administering an injection for 1 resident (#11) of 9 residents reviewed. The facility failed to date and maintain oxygen/nebulizer equipment in a sanitary manner for 5 residents (#30, #35, #43, #47, #48) of 7 residents receiving respiratory treatment.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide dignity for 1 of 18 residents (#30) being served a meal tray during the noon meal.

Inspectors wroteBased on medical record review and interview, the facility failed to follow the physician's order for a nebulizer treatment for 1 (#47) of 7 residents receiving respiratory therapy.

Inspectors wroteBased on medical record review and interview, the facility failed to have physician orders signed in a timely manner for 7 residents (#5, #20, #21, #39, #43, #1, and #2) of 51 records reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure physician orders were signed since 10/2/18 for 2 (#47, #10) of 37 residents reviewed.

Inspectors wroteBased on facility policy review, observation and interview, the faciliy failed to properly secure and store 2 of 3 oxygen tanks at the 200 Hall nurses station.

Inspectors wroteBased on policy review, observation and interview, the facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care each shift for 3 of 3 days during the survey.