Oak Hollow of Sumter Rehabilitation Center

Inspectors wroteBased on review of facility policy, record review, and interview, the facility neglected to provide services and care to Resident (R)15. Specifically, the facility failed to monitor and prevent inappropriate touching of R15 by R14, for 1 of 27 residents reviewed for abuse.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to report an allegation of abuse within the regulated timeframe, for 2 of 27 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure an assessment was completed for 1 (Resident (R)67) of 1 sampled resident reviewed for an injury of unknown origin when the resident experienced a change in condition. Specifically, on Friday, 03/27/26, Certified Nurse Assistant (CNA)15 discovered R67 had a red, swollen left arm and informed the Unit Manager (UM) of the resident's change in condition. There was no evidence that the facility assessed R67's arm until Monday, 03/30/26, when an x-ray revealed R67 had a displaced fracture of the left humerus (the long bone in the upper arm). [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide a safe, clean, and comfortable environment for residents in 2 (rooms [ROOM NUMBER]) of 7 rooms observed. Specifically, room [ROOM NUMBER] had a ceramic soap dish that was broken in half, resulting in jagged, sharp edges, and room [ROOM NUMBER] had a clogged sink.

Inspectors wroteBased on observation, interview, record review, Devilbiss 515 Series Instruction Manual review, and facility document review, the facility failed to maintain oxygen concentrators consistent with professional standards of practice for 2 (Resident (R)11 and R18) of 6 residents who utilized oxygen. Specifically, the facility failed to clean R11's oxygen concentrator filter weekly and failed to ensure preventative maintenance/servicing was completed for R11 and R18's oxygen concentrators.

Inspectors wroteBased on facility policy review, facility document review, record review, and interview, the facility failed to ensure that dialysis services were consistent with professional standards of practice including monitoring and documenting of ongoing assessment and oversight of a resident before and after dialysis treatments, and documentation of ongoing communication and collaboration with the dialysis center for 1 (Resident (R)28) of 1 resident reviewed for dialysis.

Inspectors wroteBased on facility policy review, facility document review, observation, and interview, the facility failed to ensure expired medications were not available for resident use in 1 (Medication Cart #3) of 3 medication carts. Specifically, observations revealed a bottle of naproxen (medication used for pain) and a bottle of Orajel 2X Medicated Toothache Rinse had past the manufacturer's expiration date and were available for resident administration.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that facility staff followed the proper protocols of sanitation to decrease the risk of spread of infection and maintain kitchen equipment in a clean and sanitary manner to prevent the outbreak of foodborne illness. This was evidenced by the facility staff not using the correct test strip to check the sanitation concentrations for the dish machine and the three compartment sink to monitor the sanitation level. This deficient practice had the potential to affect all the residents.

Inspectors wroteBased on observation, interview, record review and facility policy and procedure review, the facility failed to maintain an effective infection control program across three (3) of three (3) units (Units 100, 300, and 400) and in the facility's kitchen and main dining room, which potentially increased the risk of disease and infection transmission for all residents who resided in the faciity.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure Physician's Orders were followed as evidenced by observation on 4/15/25 at 11:42 a.m. in dining room, a resident (Resident (R)38) was observed to have red, swollen legs and did not have TED hose when the Physician's order required them. Failure to wear TED hose could increase the risk of blood clots, pain and ineffective treatment. The facility also failed to provide timely incontinent care to R2. The resident required staff assistance but did not receive it promptly, resulting in extended periods in a soiled brief.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to have a full time certified dietary manager (CDM) or a certified food service manager (CFSM) to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population. This deficient practice had the potential to affect all the residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop and implement an action plan for repairing and improving the facility environment. This affected all residents' safety and quality of life.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to maintain patient care electrical equipment in safe operating condition for Resident (R)1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary and comfortable homelike environment for residents and staff.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 2 (Resident (R)5 and R6) of 5 residents reviewed for abuse. Specifically, R4, who had a history of physical aggression, physically abused and injured R5. Additionally, R4 physically abused R6.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure a complete and thorough investigation was completed for 1 (Resident (R)1) of 4 residents reviewed for accidents. Specifically, R1 sustained a fall on 09/21/2024 from a mechanical lift when the sling strap broke while being transferred from the bed to a wheelchair by Certified Nursing Assistant (CNA)7 and Licensed Practical Nurse (LPN)8. R1 sustained another fall on 09/28/2024 from a mechanical lift when the shower harness strap broke while being transferred from a shower chair to the bed by CNA13 and CNA14. There was no evidence CNA13 had received re-education on mechanical lift safety after the 09/21/2024 incident. There was also no evidence of an investigation for the 09/28/2024 incident.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to provide treatment and services to prevent and/or heal Resident (R)6's pressure ulcers for 1 of 1 resident. This failure resulted in R6 acquiring multiple pressure ulcers. On [DATE] at 4:30 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy Template and informed that the failure to provide treatment and services to prevent or heal multiple pressure ulcers for R6 constitued IJ at F686 with an effective date of [DATE]. On [DATE] at 6:18 PM, the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at F686 at a lower scope and severity of D. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of 1 of 3 residents reviewed for accidents related to elopement. Specifically, Resident (R)1 had a successful elopement from the facility on 03/30/24. On 4/09/24 at 4:30 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy Template and informed that the failure to provide R(1) with adequate supervision to prevent elopement from the facility constituted Immediate Jeopardy (IJ) at F689 with a start date of 03/30/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 4/10/24 the facility presented an acceptable IJ Removal Plan. On 04/10/24, the survey team validated the facility's corrective actions and removed the IJ as of 04/09/24. [...]

Inspectors wroteBased on interview and review of facility policy, the facility failed to ensure four (4) Certified Nursing Assistants (CNAs) had a minimum of 12 hours of annual training.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure weekly body audits were completed on all residents and further failed to ensure the weekly treatment audits were completed as stated in the plan of correction. The facility further failed to review the completed weekly skin audits and the treatment audits with the monthly Quality Assurance and Performance Improvement (QAPI) committee for further follow-up and recommendations.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Registered Nurse (RN) coverage was provided for eight consecutive hours for seven days (05/27/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, and 06/25/23). This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Medication Regimen Reviews (MRRs) conducted by the pharmacist were acted upon by the physician for five of five sampled residents reviewed for MRR (Residents (R) 5, R21, R48, R40, and R49) out of a total of 31 sampled residents. This had the potential for the residents to receive unnecessary medications or the incorrect dose of the medications resulting in possible adverse consequences.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide a written notice of a transfer to the resident, the resident's Responsible Party (RP), and Ombudsman for one of one resident (Resident (R) 40) reviewed for hospitalization.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to provide a resident and the resident's Resident/Responsible Party (RP) the bed hold policy when one of one resident reviewed (Resident (R)40) for hospitalization was transferred to the hospital.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure one of one sampled residents (Resident (R) 38) in a total sample size of 31 received the correct oxygen flow rate per physician's orders and failed to ensure the oxygen unit, two nebulizer machines, two oxygen masks, and the oxygen tubing were clean and/or bagged when not in use. This failed practice has the potential to cause respiratory and other infections for residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R)5) reviewed for laboratory services had physician ordered laboratory services completed out of a sample of 31 residents. This had the potential for R5 to have unmet care needs.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a resident's medical record was accurate and reflected the resident's health status for one of six residents (Resident (R) 38) reviewed for accurate medical records out of a total of 31 sampled residents. Specifically, the facility failed to ensure documentation regarding R38's falls were included the medical record.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry room equipment was clean that included three washing machines, a container between the large washing machines, one sink, the soap dispenser, two fans and the heating unit. The facility further failed to ensure dirty equipment and items were not left directly on the floor. Failure to provide clean equipment could provide an environment conducive to bacterial growth leading to infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident (R)1 care plan was revised in a timely manner to reflect resident's condition for 1 out 2 residents reviewed.

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to perform medication accountability, discrepancy reconciliation, and disposal of four controlled medications ordered for Resident (R)2, R4 and R5.