L.m.c.- Extended Care

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record reviews, and review of the facility policy, the facility failed to ensure a significant medication error did not occur for 1 of 3 residents reviewed for medication administration. Specifically, Resident (R)1 received the medications intended for R6. R1 did not receive any of her prescribed medications. This resulted in R1 experiencing a drop in blood pressure which required hospitalization. On 09/26/23 at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/26/23 at 2:00 PM, the survey team provided the Administrator and Director of Nursing (DON) with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/17/23. [...]

Inspectors wroteBased 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.