Every finding on record at MUSC Health Chester Nursing Center

Based on review of facility policy, record review, observation, and interview, the facility failed to deliver mail to residents on Saturdays, for all residents living at the facility. Findings include: Review of the facility policy titled .Resident Rights with an effective date of 07/01/26, page 8, revealed, I. Mail. The resident has the right to privacy in written communications, including the right to: 1. Send and promptly receive mail that is unopened; and 2. Have access . During an interview on 08/19/26 at 2:45 PM, during the Resident Council (RC) Meeting, the RC President, Resident (R)9 answered no, never when the group was asked if mail is received unopened on Saturdays, adding, I've never received any mail on a Saturday. The other members nodded their heads in agreement. During an interview on 08/20/26 at 12:44 PM, the Administrator described the mail distribution process. She said all mail was delivered to the hospital by the post office. During regular business days, Monday through Friday, the Business Office Manager (BOM) brings the mail from the hospital to the facility and gives it to the Activities Director (AD). The AD then distributes the mail to the residents and assists with opening and/or reading, as needed and/or as requested. The Administrator said there had only been one grievance about mail regarding a card from a family member who claimed it contained cash. The facility investigated and concluded that they had never received the card, and the grievance was resolved. She said no one has complained about not receiving mail on Saturdays. She said that there was no access for facility staff to pick up the mail from the hospital on Saturdays because it is in a locked room. She said there are three alternate hospital staff to cover mail sorting in the Cashier's absence. The BOM stated neither she nor the AD work on Saturdays. During an interview with the AD on 08/20/26 at 12:44 PM, she described the mail distribution process. She said the mail was delivered daily to her by the BOM and then distributed the same day to the residents. It remains unopened unless the residents ask for assistance. She said she provides assistance opening and reading only when requested by the residents. She said she does this every weekday. She said the Activities Assistant works on Saturdays but does not distribute mail on Saturdays, because the activities department does not receive mail on Saturdays. The AD said that the Activities Assistant or another assigned staff will distribute the mail in her absence. During an interview and observation with the BOM on 08/20/26 at 12:44 PM, revealed a large wooden box with several rows and columns of labeled slots within the hospital's medical records department. The mail for the nursing facility was labeled CNC ([NAME] Nursing Center), and another was labeled with the BOM's name and CNC Business Office. The BOM said she gathers mail from both boxes on weekdays. She said the mail for the facility is sorted by the Cashier and placed within the boxes on weekdays. She said there was no sorting or distribution on Saturdays and holidays. She said there was no access to pick up the mail from the hospital on Saturdays, and it is in a locked room until the Cashier returns Monday (or the next business day, if it is a holiday.) During an interview with the Cashier on 08/20/26 at 12:59 PM, she said she sorts the mail every day, Monday-Friday after it is delivered by the mailman. She then places the mail in the appropriate boxes within the Medical Records Department. She then emails the facility Administrator and BOM to let them know she has placed mail in the facility's boxes. She said she does not work on Saturdays. The Cashier said the Saturday mail delivery is received by the registration clerks and locked up in their office until she returns to sort it on Monday (or the next business day). During an interview with the Administrator on 08/20/2026 at 1:15 PM, revealed the AD or her designee retrieves the mail when BOM is not present Monday-Friday. During an interview with R9 on 08/20/26 at 2:05 PM, revealed he has not received mail on Saturdays since admission. During an interview with R6 on 08/20/26 at 2:07 PM, revealed he has not received mail on Saturdays since admission. During an interview with R49 on 08/20/26 at 2:08 PM, revealed he has not received mail on Saturdays since admission. During an interview with R23 on 08/20/26 at 2:11 PM, revealed he has not received mail on Saturdays since admission. During an interview with R13 on 08/20/26 at 2:13 PM, revealed he has not received mail on Saturdays since admission.

Based on review of the facility policy, observations, and interviews, the facility failed to properly store and label food items and ensure expired food was discarded in accordance with professional food safety standards in the walk-in freezer, refrigerators, and dry storage shelf. Failure to properly label and store food has the potential for widespread harm of food-borne illnesses. Findings include: Review of the facility policy titled, Food and Supply Storage, with a revision date of 01/25 states, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Under Procedures, it states, Cover, label and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on a [NAME] orange label. Products are good through the close of business on the date noted on the label. Refer to the Food Storage Chart in this policy to determine discard dates for food items. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Under the Dry Storage, it states Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight-fitting lids. Label both the bin and lid . During the initial kitchen observation on 06/03/25 at 10:25 AM, multiple items were found without labels indicating the open date and/or use-by date. Items included: cut tomatoes, cut melons, shredded carrots, grapes and a tray of romaine lettuce in the walk-in produce refrigerator; frozen chicken in box, and Ken's Golden Italian Dressing (one gallon jug) in the middle walk-in refrigerator; an opened bag of cut chicken pieces, an opened box of ground beef patties, an opened bag of frozen pizzas in the walk-in freezer; and multiple spices (granulated garlic, paprika, ground cayenne pepper, lemon pepper seasoning salt, fajita marinade & seasoning), two packages of light brown sugar (32 oz each), [NAME] peanut butter (five lbs) on dry storage shelf. One jug of Tea (one gallon) was found opened with no label indicating the open date or use-by date in the refrigerator, in the nourishment room of the nursing center (located in the staff break room). Expired food items were also found, including: two gallons of milk (expiration dates of 05/29/25 and 06/02/25), one bowl of cut zucchini/tomatoes (use-by date of 06/02/2025), cut melons (use-by date of 06/01/2025) in the walk-in produce refrigerator; shredded Parmesan cheese (use-by date of 05/29/2025) in the middle walk-in refrigerator; and one box of vegetable broth (4.5 L/1.19 g) with label dated 05/03/2025 on the dry food storage shelf. A bag of open shredded Parmesan cheese was also found on the dry storage shelf. No label with open or use-by dates were found on the package of Parmesan cheese. All expired items were disposed of immediately by the Food Service Manager (FSM). There were cut tomatoes and one bag of grapes in the walk-in produce refrigerator; and one box of ground beef patties and one bag of frozen pizzas in the walk-in freezer opened, and not sealed close. All items were discarded by the Food Service Manager. During an interview with the [NAME] on 06/05/25 at 2:20 PM, the [NAME] stated when she opens a food package or jar, she must put a label on it stating what it is, the date she opened it, and the date they need to use it by. During an interview with the FSM, District Food Service Manager (DM), and Chef on 06/05/25 at approximately 2:45 PM, the FSM and DM stated, The staff receive monthly training through their company. We also do daily meetings to discuss any current issues. The FSM stated, Labeling and packaging has been an ongoing issue. I do daily audits with the Chef to walk around and check the refrigerators and freezers and the food within them. The FSM stated, I know the labels were not what they should have been when the refrigerators and freezer were surveyed on Tuesday, 06/03/25, and the problem started when the labeling machine broke. The staff was having to put on the labels themselves. The Chef stated, We have just received the labeling machine back. The FSM stated, My expectation is for staff to label and package opened containers of food with the dates it was opened, and when it should be used by. During an interview with the Food Service Supervisor on 06/05/25 at 3:30 PM, she stated, We use a label machine that will automatically give the opened and use-by dates. They put in the name of the food, and the machine will automatically fill in the date and when to use the food by. Anytime they open something, they are supposed to put a label on it. If something doesn't have a label or doesn't have a date of when to use it by, I will throw it away.

Based on observation, interview, and record review, the facility failed to ensure dependent residents received showers/baths including the washing of hair for one of one resident reviewed for activities of daily living (ADLs), (Resident (R) 46) out of a total sample of 13. R46 was observed with uncombed and greasy hair; and facility documentation of showers/baths was incomplete. Findings include: Review of the facility's policy titled Residents (sic) Activity of Daily Living revealed Ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and Ensuring (sic) that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs . Showers/baths will be offered to residents twice a week. Bed baths will be performed between shower days upon resident request . The policy also had Documentation and Patient management but there was no documentation noted under this heading in the facility's policy. An observation was made on 04/08/24 at 11:30 AM. R46's hair had the appearance of being uncombed and greasy. R46 stated, It doesn't feel good. Review of R46's Face Sheet, provided by the facility, revealed R46 was admitted on [DATE] with diagnoses including history of cerebral vascular accident (stroke) and generalized weakness. Review of R46's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 02/08/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R46 was cognitively intact. R46 was also coded for shower/bathe self and personal hygiene as requiring substantial/maximal assistance with the helper performing more than half of the effort. Review of R46's care plan, dated 08/11/23 and provided by the facility, revealed Problem: ADLs with the Description as indicating [R46] has an ADL self-care performance deficit r/t [related to] hx [history] of CVA [cerebral vascular accident] and generalized weakness. [R46] required maximum assistance of one staff member to provide baths/showers as scheduled and as necessary. [R46] also required moderate to maximum assistance of one staff member for personal care and oral care. Review of R46's documentation of ADLs on the Flowsheet located in the EMR revealed beginning on 03/15/24 through 03/18/24, and 03/20/24 through 03/31/24, there were no showers and/or baths documented on the ADL Flowsheet, baths/showers were scheduled twice a week and as needed. Review of R46's documentation of ADLs under the GG tab in the EMR revealed no documentation for showers and/or baths documented for these dates. During an interview on 04/11/24 at 3:00 PM, Unit Manager (UM) confirmed there was no documentation in the EMR for baths and/or showers on the above documented dates. During an interview on 04/11/24 at 4:00 PM, the Director of Nursing (DON) stated, On 03/15/24, we began charting these [baths and showers] in a different way using 'GG' instead of the 'ADL' flowsheet. When the CNAs [certified nursing assistants] documented, it looks like they misunderstood how to answer the questions for bathing. The administrator stated, We didn't know there was a problem until you started asking for the documentation of the ADLs for bathing for this resident. The DON confirmed there was missing documentation for the above dates for bathing/showers in R46's EMR.

Based on record review and staff interview, the facility failed to ensure each Medicare resident and/or resident representative (RP) whose Medicare therapy services were terminated received a copy of form Centers for Medicare and Medicaid Services (CMS) 10123 Notice of Medicare Non-Coverage (NOMNC) and CMS -10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for two of three residents (Resident (R) 48, and R42) reviewed for beneficiary notices out of a total sample of 13 residents. This failure in not providing a copy of CMS 10055 and CMS form 10123 to the resident and/or resident representative could potentially impinge on the resident being able bill Medicare in appealing the non-covered services correctly and receive the Medicare Services Notice (MSN) for further instructions in the appeal process. Findings include: The facility's policy on beneficiary notices was requested but were not received prior to the exit conference on 04/11/24. 1. Review of R48's Face Sheet that was provided by the facility revealed on 08/08/23, R48 was admitted for rehabilitation and remained in the facility for long term care (LTC). R48's last covered day (LCD) of Medicare Part A services was 11/18/23. Review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) completed by the facility revealed R48 had a facility-initiated discharge from Medicare Part A services. The facility indicated R48 was provided with SNF ABN, Form CMS-10055 and NOMNC, Form CMS 10123. Review of R48's Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), provided by the facility, revealed the following options: Option 1. I want the care listed above. I want Medicare to be billed for an official decision on payment which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I will be responsible for paying, but I can appeal to Medicare by following the directions on the MSN. Option 2. I want the care listed above, but do not bill Medicare, I understand that I may be billed now because I am responsible for the payment of the care. I cannot appeal because Medicare won't be billed. Option 3. I don't want the care listed above. I understand that I am not responsible for paying, and I can't appeal to see if Medicare would pay. Review of the SNF ABN revealed the Business Office (BO) 1 documented verbal consent was obtained from R48's family member ((F)2). None of the three above options were selected. Review of R48's NONMC, provided by the facility, was not signed by F2 or R48. During an interview on 04/11/24 at 9:16 AM, the Business Office (BO) 1 stated, I mailed them a copy, but I do not have documentation to say that this was done. I forgot to mark the option that R48'2 RP [resident representative] decided to go with. The BO said she got confirmation over the phone, however did not have any documentation. During an interview on 04/11/24 at 9:22 AM, the Administrator confirmed the areas on R48 NOMNC where the options were not marked needed to have been marked. The Administrator confirmed the verbal consents obtained for the NOMNC's should be documented on how the RP received copies of what was consented to over the phone. During a phone interview on 04/11/24 at 10:57 AM, F2 stated they had not spoken to BO1 about this. F2 stated, I would have remembered it because if we had to pay for it, then we would have told her that we could not afford it. I didn't get any paperwork on this either. 2. Review of R42's face sheet that was provided by the facility revealed R42 was admitted to the facility on [DATE]. Medicare Part A skilled services episode had a start date of 02/26/24 with the last covered date (LCD) on 03/15/24. R42 remained in the facility. Review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) completed by the facility revealed R48 had a facility-initiated discharge from Medicare Part A services. The facility indicated R48 was provided with SNF ABN, Form CMS-10055 and NOMNC, form CMS 10123. During an interview on 04/11/24 at 9:16 AM, BO1 stated, I mailed them a copy, but I do not have documentation to say that this was done. BO1 did not have copies of R42's SNF ABN or NOMNC. During an interview on 04/11/24 at 9:22 AM, the Administrator confirmed there was no documentation of the NOMNC or SNF ABN for R42. During a phone interview on 04/11/24 at 10:40 AM, F1, resident representative for R42, stated, I haven't received anything regarding this. Plus, I do not understand anything about what you are talking about. I don't remember any [BO1] calling me about [R42]. When asked if F1 had received paperwork explaining the termination of these services, F1 replied I haven't received anything talking about this.

Based on observation, interview, record review, and policy review, the facility failed to remove loose pills from one of three medication carts and failed to return discontinued medications to the pharmacy for two residents (Resident (R) 13 and R42). Findings include: Review of facility's policy titled ''Medication Storage'' revised 02/02/24 stated, ''. The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Drugs and biologicals shall be stored in the packaging, containers [sic] or other dispensing systems in which they are received . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Such drugs shall be returned to the dispensing pharmacy or destroyed . Medications will be discarded according to policy .'' Review of facility's policy titled ''Disposal of Medications and Medication-Related Supplies'' dated October 2018 stated, ''When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked 'discontinued' and securely stored until destroyed . Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (such as unit-dose packages or sealed containers) may be returned to the pharmacy in accordance with the Medication Return policy . Discontinued medications not returned to the pharmacy are destroyed in accordance with the Medication Destruction policy .'' Review of R13's ''Face Sheet'' provided by the facility indicated she was admitted to the facility on [DATE]. Review of R13's quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 02/07/24 indicated she had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating she was cognitively intact. Additionally, she had a diagnosis of depression. Review of R13's ''Medication Orders'' provided by the facility indicated sertraline (antidepressant medication) 25 milligram (mg) tablets were ordered 11/07/22 and discontinued 12/14/23. Review of R42's ''Face Sheet'' provided by the facility indicated she was admitted to the facility on [DATE]. Review of R42's quarterly MDS with an ARD of 02/09/24, indicated she had a BIMS score of 11 out of 15 indicating she was cognitively intact. Additionally, she had a diagnosis of manic depression. Review of R42's ''Medication Orders'' provided by the facility indicated citalopram (antidepressant medication) 10 mg tablets were ordered 09/07/23 and discontinued 02/26/24. During an observation and interview on 04/10/24 at 9:48 AM revealed a medication cart for Hall One, in use by Licensed Practical Nurse (LPN)1, had one loose white tablet and one loose capsule in the medication cart. LPN1 confirmed loose medications were located in the cart and should have been removed. Additionally, R13 had eight discontinued sertraline hydrochloride (HCl) 25 mg tablets in the bottom drawer of the cart dispensed on 11/27/23. LPN1 confirmed sertraline HCl was discontinued on 12/14/23. R42 had six discontinued citalopram 10 mg tablets in the bottom drawer of the cart dispensed on 01/31/24. LPN1 confirmed citalopram 10 mg was discontinued on 02/26/24. LPN1 confirmed that discontinued medications should have been returned to the pharmacy. LPN1 stated that usually the night nurses log the medications to be returned to the pharmacy and place them in a box in the medication storage room. During an interview on 04/11/24 at 9:01 AM, the Unit Manager (UM) stated that when a medication was discontinued by the Nurse Practitioner or Medical Doctor, the nurse receiving the order entered the order in the EMR and should remove the medication immediately. The UM stated, typically, the night shift nurses remove all discontinued medications and place the medications in the medication room, write the medication on the medication reconciliation form and then send the discontinued medications back to the pharmacy. The UM stated her expectation was for the discontinued medications to be removed from the cart and verified that all nurses were trained in this process. The UM confirmed that R13's sertraline was started on 11/07/22 and discontinued 12/14/23. The UM confirmed that R42's citalopram was started on 09/07/23 and discontinued on 02/26/24. During an interview on 04/11/24 at 9:53 AM, the Director of Nursing (DON) stated she was made aware yesterday of the two loose pills and of discontinued medications for R13 and R42. Every nurse was trained to remove medications from the cart when they were discontinued. The DON stated there was a box in the medication room where the nurses should put the discontinued medications; the pharmacy then picks up any non-narcotic medications to be returned. The DON stated her expectation was for the nurses to follow facility policies.

Based on record review and facility staff review, the facility failed to initiate a physician order for an indwelling urinary catheter change for one of one resident reviewed (Resident (R) 46) for catheters out of 13 sampled residents. This failure could have resulted in R46's indwelling urinary catheter not being changed every four weeks as per the urologist's recommendation. Findings include: Review of R46's Face Sheet, provided by the facility revealed R46 was admitted on [DATE] with diagnosis of obstructive uropathy (urinary tract disorder that occurs when urine cannot drain through the tract). Review of R46's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/08/24, revealed the resident had an indwelling urinary catheter. Review of the after visit note from R46's urologist appointment, dated 03/21/24 and provided by the facility, revealed R46's indwelling urinary catheter was to be changed every four weeks. Review of R46's care plan, dated 01/19/24 and provided by the facility, revealed the resident had an indwelling catheter with interventions of . Nursing staff to change Foley [type of indwelling urinary catheter] catheter and urinary bag as needed . Review of R46's physician orders, provided by the facility, revealed an order dated 03/25/24 which stated, Change Foley bag every month. And on 03/26/24, there was another physician order which stated, Change Foley Catheter PRN (as needed). There was not an order to change R46's catheter every four weeks, per the urologist's recommendation. During an interview on 04/10/24 at 6:12 PM, unit manager (UM) stated, I called Dr. [name of physician] on 03/20/24 and she gave me an order to change the Foley [catheter] at that time due to having problems with the existing Foley. When doing that, I forgot to write the order for the Foley [catheter] to be changed every four weeks. UM confirmed there should have been an order to change the Foley catheter every four weeks and there was not one written. During an interview on 04/11/24 at 4:02 PM, the Director of Nursing (DON) stated, There was an order for the Foley catheter to be changed prn [as needed] but there was not an order to have the catheter changed every four weeks.

Based on review of the facility policies, record reviews, and interviews, the facility failed to update and revise the code status on comprehensive care plans for two residents of 13 sampled residents (Resident (R) 14 and R22). Findings include: Review of the facility's policy MDS [Minimum Data Set] Comprehensive Care Plan, revised on [DATE] indicated . The Care Plan will reflect the current and best practice standards to provide care . The Care Plan will be revised on an on-going basis to reflect changes in the Resident and the services the Resident is receiving . Review of the facility's policy titled, ''MDS Comprehensive Care Plan'' revised [DATE] stated, ''.The Care Plan will be revised on an on-going basis to reflect changes in the Resident and the services the Resident is receiving .'' 1. Review of R14's ''Face Sheet,'' provided by the facility, indicated R14 was admitted to the facility on [DATE]. Review of R14's ''Care Plan,'' dated [DATE] and provided by the facility, indicated R14's code status was full code, indicating if the resident's heart stopped beating and/or stopped breathing, all resuscitation procedures (including cardiopulmonary resuscitation (CPR), chest compressions, intubation, and defibrillation) would be provided to keep them alive. Review of R14's quarterly MDS with an Assessment Reference Date (ARD) of [DATE], included a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating she was moderately cognitively impaired. Review of R14's ''Physician Orders,'' provided by the facility and dated [DATE], included, ''Allow natural death: do not provide resuscitative measures: (continue appropriate medical treatment). Review of R14's ''Emergency Medical Services Do Not Resuscitate Order (DNR)'' dated [DATE] and signed by R14 included ''. no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest .'' During an interview on [DATE] at 2:35 PM, R14 confirmed her code status was DNR. During an interview on [DATE] at 6:37 PM, MDS Coordinator (MDSC) confirmed R14's care plan indicated the resident's code status was full code, however, her physician order and signed advance directive stated DNR. MDSC stated she was probably not notified of the code status. Additionally, the Unit Managers and Social Workers perform monthly audits of code status. During an interview on [DATE] at 6:37 PM, the Unit Manager (UM) confirmed that R14's care plan indicated R14 was full code, however, her physician order and signed Emergency Services DNR was DNR. Additionally, the UM stated that when a resident went out to the hospital they automatically returned as a full code and maybe that was why her care plan was not changed back to DNR status. The UM confirmed the status should have been updated to DNR after return from the hospital on [DATE]. During an interview on [DATE] at 9:19 AM, the Director of Nursing (DON) stated that normally the MDSC ran a report every morning, with weekly audits for code status, to verify physician orders match the advance directive on file. The DON stated they recently noticed that when residents had a leave of absence, the code status automatically fell off the order and was entered as full code. The DON stated R14 had a leave of absence to the hospital from [DATE]-[DATE] and maybe her status was not updated on her care plan but should have been. 28306 2. Review of R22's Face Sheet provided by the facility indicated R22 was admitted to the facility on [DATE]. Review of the R22's quarterly MDS with an ARD of [DATE] revealed the resident had a BIMS score of 15 out of 15, which indicated R22 was cognitively intact. Review of R22's care plan, provided by the facility, revealed a problem listed for Advance Care Directives revealed a description which stated, [R22] is a Full Code. Review of R22's active physician orders, provided by the facility revealed an order dated [DATE] which indicated, Allow Natural Death: Do Not [sic] provide resuscitative measures. During an interview on [DATE] at 6:00 PM, MDSC confirmed that code status was incorrect on the care plan which had the resident listed as full code. During an interview on [DATE] at 4:25 PM, the DON stated, We found out that the person that was doing the audits on advance directives was not including the person that updated the care plans.

Based on observation and interview, the facility failed to maintain the dumpster area in a sanitary manner to prevent the harborage of pests 3 out of 3 days of the survey. A foul-smelling liquid leaked out of the dumpster onto the asphalt extending as far as approximately 15 feet across a parking lot; there were flies in this area during each observation. In addition, there was garbage on the asphalt near/along the edge of the dumpster all 3 days of the survey. Findings include: During the initial kitchen inspection conducted on 08/08/22 between 9:53 AM-10:47 AM, the dumpster area was observed with the Chef. There was a large garbage compactor/dumpster located behind the facility on asphalt adjacent to a parking area. A strong foul odor was noted emanating from the compactor and there was liquified refuse under and around the compactor approximately three by two feet in size. There was also garbage including pieces of paper, plastic, cardboard pieces, wrappers, a spoon, a metal lid, and plastic beverage bottle lid on the ground along the edge of the dumpster and extending out several feet onto the asphalt. There were numerous flies buzzing around the liquified refuse area. The Chef verified the foul odor, presence of garbage pieces on the asphalt, and flies, stating it looked like the dumpster was leaking the contents onto the pavement. During a follow up inspection on 08/09/22 between 11:29 AM-11:49 AM, the dumpster area was observed with the Director of Nutrition/Certified Dietary Manager (CDM). The foul-smelling areas of liquified refuse remained but covered a larger area than the day before, of approximately three feet by three feet. The Director of Nutrition stated it smelled bad and he had not seen the contents leak onto the asphalt previously, indicating this needed to be corrected. The Director of Nutrition stated the Chef had not notified him of the observation the day before. There were flies buzzing in around the liquified refuse. Garbage remained on the ground along the edge of the dumpster and around the soiled area including small pieces of paper, plastic, cardboard, wrappers, and a plastic lid remained on the pavement. The Director of Nutrition stated the maintenance department oversaw the dumpster area; however, all staff who used the dumpster had responsibility. The Director of Nutrition stated the compactor contents were picked up twice a week. During a follow up inspection on 08/10/22 at 8:33 AM, the foul-smelling liquid continued to be present on the asphalt. However, it covered a larger area of approximately three by four feet with an offshoot extending out from the large liquified area approximately 10 more feet to where vehicles were parked. Garbage was noted on the pavement in this area including pieces of plastic, paper, cardboard, a glove, and lid to bottle. There were flies buzzing around the liquified refuse. During an interview on 08/10/22 at 8:51 AM with the Director of Facilities and the Administrator, the Director of Facilities stated that he was notified of the problem yesterday and had observed the dumpster area. The Director of Facilities verified there was a foul-smelling fluid on the paved area from the compactor. They stated there was no policy related to maintenance of the dumpster area and previously no one person or department was responsible for maintaining it in a sanitary manner. Neither the Director of Facilities nor the Administrator stated they had been aware of the leaking compactor until the Director of Nutrition notified them on 08/09/22.

Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (1) of five (5) residents reviewed for unnecessary medications and one (1) of three (3) residents reviewed for tube feedings. Resident #17's [MEDICATION(S)] (fast-acting insulin) and Resident #42's tube feeding flush were not administered as ordered. Findings include: Review of the facility policy titled Medication Administration with an effective date of 5/19/2021 revealed Purpose: To provide guidelines for the administration of medications in an organized and safe manner. Policy: It is the policy of MUSC Health Chester Nursing Center that the following procedures apply to the administration (sic) medications (which includes oxygen). Medications are administered as prescribed with good nursing principles and practices which are legally authorized. General Guidelines: .Medications are administered according to the physician's orders, medication list, or literature accompanying the drug. Medications are to be administered exactly as ordered. Administration .Read medication label al (sic) least (3) times and compare with MAR [Medication Administration Record] for name of medication, dosage, form and route at time of administration. 1. Resident #17 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. Record review of Resident #17's Physician's Orders revealed [MEDICATION(S)] 100 Unit/ML [milliliter] Soln [solution] inject sliding scale before meals and at bedtime as follows: MOD [moderate] Dose SS [sliding scale] 70-149 = 0 units, 150-200 = 3 units, 201-250 = 6 units, 251-300 = 9 units, 301-350 = 12 units, 351-400 = 15 units, >400 = 18 units and call MD [Medical Doctor] start date of 5/11/2021. Record review of Resident #17's MAR from May 11th through May 26th, 2021 revealed the following: 5/13/21 blood sugar 215, three (3) units of insulin documented as administered, 5/13/21 blood sugar 177, zero (0) units of insulin documented as administered, 5/14/21 blood sugar 274, six (6) units of insulin documented as administered, 5/17/21 blood sugar 200, zero (0) units of insulin documented as administered, 5/18/21 blood sugar 154, zero (0) units of insulin documented as administered, 5/20/21 blood sugar 185, two (2) units of insulin documented as administered. During an interview on 5/27/21 at 10:44 a.m. with Nurse Practitioner (NP) #1, s/he stated that nurses could not make the decision to reduce a resident's insulin dose; it required an order from the provider. NP #1 stated that it was her/his expectation that the nurses carry out orders as prescribed. NP #1 stated that the units of [MEDICATION(S)] that were not administered on 5/13/21, 5/14/21, 5/17/21, 5/18/21, and 5/20/21 did not have a significant negative impact on Resident #17. During an interview on 5/27/21 at 12:53 p.m. with Resident #17, s/he stated that s/he never refused his/her insulin and did not request a lower dose than what s/he was prescribed. Resident #17 stated that s/he knew how important it was for his/her health to get the insulin that was prescribed. An observation of Resident #17 revealed the resident was sitting up in his/her wheelchair in no apparent distress. During an interview on 5/27/21 at 1:04 p.m. with Licensed Practical Nurse (LPN) #2, s/he verified that s/he administered Resident #17's [MEDICATION(S)] on 5/20/21 at 4:52 p.m. LPN #2 stated that s/he might have typed in two (2) units of [MEDICATION(S)] in the MAR on accident. LPN #2 stated that s/he believed that s/he administered three (3) units as per the sliding scale but stated, I'm not sure. During a phone interview on 5/27/21 at 5:04 p.m. with LPN #1, s/he stated that s/he thought the sliding scale for Resident #17's [MEDICATION(S)] started with a blood sugar reading of 201 and above. LPN #1 stated that you can click on the order in the MAR and see the sliding scale, but s/he thought it started with a blood sugar reading of 201, and this why s/he did not administer [MEDICATION(S)] to Resident #17 on 5/13/21 at 5:48 p.m., 5/17/21 at 12:08 p.m., and 5/18/21 at 1:27 p.m. During an interview on 5/28/21 at 8:45 a.m. with the Director of Nursing (DON), s/he stated that s/he reviewed Resident #17's MAR and verified the documented errors. The DON stated that it was her/his expectation that nurses follow physician's orders as prescribed. 2. Resident #42 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Quarterly MDS assessment dated [DATE] revealed BIMS of four (4), meaning the resident had Severe cognitive impact. Further review revealed the resident had a feeding tube and received an average fluid intake per day by IV (Intravenous) or tube feeding of 501 cc [cubic centimeter] or more. Record review of Resident #42's Physician's Orders revealed Glucerna 1.2 cal [calorie] liquid Continuous feed 65mL/hr [milliliters/hour] with 150ml flush every four (4) hours. Check residuals every four (4) hours and follow guidelines if greater than 250ml return to stomach if no distention pain. Notify physician. Hold feedings and meds [medications] x 1 hour thm [sic] recheck if still greater than 250mL Notify physician. Start date 4/16/21. During an observation on 5/25/21 at 11:30 a.m., Resident #42's continuous tube feeding was set at 65ml/hr with 1336 ml total feed and a flush set at 100ml/hr with 489 ml total flush. Resident #42 was observed in bed watching television in no apparent distress. During an observation on 5/26/21 at 8:39 a.m., Resident #42's continuous tube feeding was set at 65ml/hr with 1098 ml total feed and 100ml/hr flush with 451 ml total flush. Resident #42 was observed in bed receiving a bed bath in no apparent distress. During an observation with RN #1 of Resident #42 on 5/26/21 at 10:47 a.m., RN #1 verified that Resident #42's feeding pump was set at 65ml/hr feed and 100ml/hr flush with a total feed of 1188ml and total flush of 451ml. RN #1 verified with the provider's order that the flush setting was incorrect. RN #1 stated that the flush was to be set at 150ml every four (4) hours as ordered. During an interview on 5/26/21 at 1:00 p.m. with the DON, s/he stated that in September 2020, s/he provided an in-service during the monthly staff meeting. The DON provided an outline of the in-service dated 9/16/20, which stated tube feedings management and flushes. Review on operating pump. The DON stated that s/he did not provide training material, s/he stated that s/he just talked about the tube feeding and pump during the in-service. During an interview on 5/26/21 at 1:25 p.m., the Medical Doctor (MD) #1 verified Resident #42's order for Glucerna 1.2 cal continuous feed 65ml/hr with 150ml flush every four (4) hours. MD #1 stated that the 100ml of flush that was provided every four (4) hours versus the 150ml flush every four (4) hours that was ordered did not have a negative impact on the resident. During an interview on 5/28/21 at 8:57 a.m. LPN #2, stated that s/he hung Resident #42's tube feeding and flush at 5:30 a.m. on 5/24/21. LPN #2 stated that s/he checked the MAR for the order, hung the feeding and flush, but started talking with the resident and got distracted. LPN #2 stated that the H2O flush was to be set at 150ml flush every (four) 4 hours. LPN #2 stated s/he could not remember if s/he checked the tube feeding pump settings or if s/he overlooked it. LPN #2 stated that the pump settings must be checked every four (4) hours when the resident's residual was checked. S/he stated that s/he did not know if the pump would reset on its own. LPN #2 stated that s/he had received training on the feeding pump. During an interview on 5/28/21 at 11:45 a.m. with the Unit Manager, S/he stated that s/he performed compliance rounds daily but did not document the rounds. The Unit Manager stated that s/he got with the nurse and the DON if there were any discrepancies. The Unit Manager stated that s/he had not performed Care Plan and MAR audits. The Unit Manager stated that s/he had checked on Resident #42's pump settings during her/his rounds and has had no concerns. The Unit Manager stated that if the nurses did not hit save on the pump after they enter the settings, it would default back to the previous setting. The Unit Manager stated that nurses were to check the pump during the scheduled residual checks.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive person-centered care plan for one (1) of five (5) residents reviewed for unnecessary medications and one (1) of three (3) residents reviewed for tube feedings. Care Planned interventions to address Resident #17's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Planned interventions to address Resident #42's Nutrition/Hydration status were not implemented in accordance with the Care Plan and Physician's Orders. Findings include: Review of the facility policy titled Resident assessment dated [DATE] revealed, .In accordance with each resident's plan of care, all services provided or arranged by the facility meet professional standards of quality and are provided by qualified persons . 1. Resident #17 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. Record Review of Resident #17's Care Plan with a review date of 5/25/21 revealed a Focus of DM [Diabetes Mellitus] with a goal of [resident] will have no complications related to diabetes through the review date and an intervention of Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #17's Physician's Orders revealed [MEDICATION(S)] [fast-acting insulin] 100 Unit/ML [milliliter] Soln [solution] inject sliding scale before meals and at bedtime as follows: MOD [moderate] Dose SS [sliding scale] 70-149 = 0 units, 150-200 = 3 units, 201-250 = 6 units, 251-300 = 9 units, 301-350 = 12 units, 351-400 = 15 units, >400 = 18 units and call MD [Medical Doctor] start date of 5/11/2021. Record review of Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to administer insulin on a sliding scale based on the resident's blood sugar levels. For example: 5/13/21 blood sugar 215, three (3) units of insulin documented as administered, 5/13/21 blood sugar 177, zero (0) units of insulin documented as administered, 5/14/21 blood sugar 274, six (6) units of insulin documented as administered, 5/17/21 blood sugar 200, zero (0) units of insulin documented as administered, 5/18/21 blood sugar 154, zero (0) units of insulin documented as administered, 5/20/21 blood sugar 185, two (2) units of insulin documented as administered. 2. Resident #42 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BIMS of four (4), meaning the resident had Severe cognitive impact. Further review revealed the resident had a feeding tube and received an average fluid intake per day by IV (Intravenous) or tube feeding of 501 cc [cubic centimeter] or more. Record review of Resident #42's Care Plan with a revision date of 5/21/21 revealed a focus of NUTRITION/HYDRATION with an intervention to Provide, serve diet as ordered. NPO [nothing by mouth] due to dysphagia. Enteral Nutrition Order: Glucerna 1.2 65 mL/hr [milliliters per hour] continuous feeding, with 150 mL of H2O [water] flush q2h [every two hours]. Check residuals q4h [every four hours]. Hold feeing (sic) if residuals are greater than 250 mL. Review of Resident #42's medical record revealed the Nutrition and Hydration Care Planned interventions were not developed in accordance with the Physician's order. The Physician's order with a start date of 4/16/21 stated, Glucerna 1.2 cal [calorie] liquid Continuous feed 65mL/hr [hour] with 150ml flush every 4 hours. Check residuals every 4 hours and follow guidelines if greater than 250ml return to stomach if no distention pain. Notify physician. Hold feedings and meds x 1 hour thm [sic] recheck if still greater than 250mL Notify physician. During an observation on 5/25/21 at 11:30 a.m. Resident #42's continuous feeding was set at 65ml/hr with 1336 ml total feed and a flush set at 100ml/hr with 489 ml total flush. During an observation on 5/26/21 at 8:39 a.m. Resident #42's continuous feeding was set at 65ml/hr with 1098 ml total feed and 100ml/hr flush with 451 ml total flush. During an observation on 5/26/21 at 10:47 a.m. with RN #1 of Resident #42, RN #1 verified that Resident #42's feeding pump was set at 65ml/hr feed and 100ml/hr flush with a total feed of 1188ml and total flush of 451ml. RN #1 verified with the providers' order that the flush setting was incorrect. RN #1 stated that the flush is to be set at 150ml every four (4) hours as ordered. During an interview on 5/28/21 at 11:17 a.m. with the MDS Coordinator, s/he stated that it was the responsibility of the nursing staff to ensure that the nursing Care Plan interventions were implemented. The MDS Coordinator stated that s/he did not perform audits or compliance checks on Care Plan interventions. Care plan meetings and reviews were held on admission, quarterly, and after a change in condition. During an interview on 5/28/21 at 11:36 a.m. with the Director of Nursing (DON), s/he stated that all nursing staff had access to the resident's Care Plan. The nursing staff did not have the ability to change the Care Plan, but if interventions were not working or if interventions needed to be added and/or changed, the nurses could report to the DON and MDS Coordinator. The DON stated that s/he did not perform audits or compliance checks on Care Plan interventions. The DON stated that s/he did not perform audits on MARs. The DON stated that the Risk Manager and the Unit Manager were responsible for ensuring accuracy and compliance of Care Plan interventions. During an interview on 5/28/21 at 11:45 a.m. with the Unit Manager, s/he stated that s/he performed compliance rounds daily but did not document the rounds. The Unit Manager stated that s/he had not performed Care Plan and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Unit Manager stated that nurses were to check the pump during the scheduled residual checks. During an interview on 5/28/21 at 11:50 a.m. with the Risk Manager, s/he stated that s/he did compliance rounds twice a week for Care Plan interventions and orders. S/he stated that s/he did not document compliance rounds. The Risk Manager stated that during compliance rounds, s/he had watched medication pass but did not go back and audit the MARs and Care Plan. During an interview on 5/28/21 at 12:03 p.m. with Licensed Practical Nurse (LPN) #2, who was assigned to care for Resident #42 and Resident #17. LPN #2 stated that when s/he was working, s/he would go through and ensure that Care Plan interventions were followed for her/his residents. LPN #2 stated that her/his checks were not documented, but if an intervention was a treatment or medication, it would be in the MAR for documentation. If a change was made to the Care Plan, s/he would be informed about it during the shift meeting.

Based on observation, record review, and interview, the facility failed to develop a baseline care plan to include mental health interventions for one (1) of one (1) resident (Resident #147) reviewed for mood and behaviors. Findings include: The resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #147 baseline care plan dated 5/20/21 revealed no care plan for mental health needs or behaviors. Review of Resident #147's Admission Progress Note dated 5/20/2021 at 6:54 p.m. revealed resident transferred from med-surg to CNC rm [room] [number] via stretcher x2 [two-person assist]. resd [resident] agitated and hollering .alert x1 c [with] confusion. Resd hollering and swinging at staff. [resident] makes attempts to get up unassisted. Resd keeps hollering Call the ambulance, take me to the hospital. That dr [doctor] owes me money.Per med-surg nurse resd refuses care/ meds [medications], can be combative c [with] staff and makes attempts to get up unassisted. Review of Resident #147's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #147's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . alert x1 confusion. resd attempting to get up unassisted multiple times. Review of Resident #147's Nurse's Note dated 5/20/2021 at 8:15 p.m. revealed .resd can be combative, loud and confused .Refuses care and meds daily . Review of Resident #147's Nurse's Note dated 5/20/2021 at 8:22 p.m. revealed resd in room sitting on side of bed/ has made multiple attempts to get [up] unassisted. Nurse walking by room and observed resd sliding himself on floor/ floormats at bedside. Resd states, I gotta go, take to me to the hospital. The dr [doctor] owes me money. Review of Resident #147's Nurse's Note dated 5/20/2021 at 9:00 p.m. revealed PRN [as needed] [MEDICATION(S)] was effective resident lying quietly in bed at present no longer yelling out or attempting to get OOB [out of bed] unassisted. Easily aroused asking for grits and coffee, commented once about going to the ER [emergency room ] for [his/her] leg, resident was reminded that the Dr had to remove [his/her] leg, stated Oh, OK. Resident has some confusion note during the conversation was able to redirect [him/her] at times. Bed in low position with mats at bedside. During an observation on 5/26/21 at 10:40 a.m., Resident #147 was heard threatening staff making comments such as I'll take care of you and you have five minutes to get it to work or I'm gonna put you down. Staff were attempting to calm the resident down and the Medical Doctor (MD) was called to assess the resident. During an observation on 5/26/21 at 12:23 p.m. Resident #147 was observed in the hallway near his/her room door yelling and cursing at staff. The Administrator was able to calm the resident down and have the resident return to his/her room. During an interview on 5/26/21 at 12:05 p.m. with the Minimum Data Set (MDS) Coordinator, s/he stated that nursing did the baseline care plan and placed them in the residents' hard charts. The MDS Coordinator stated that s/he did not review the baseline care plans. S/he stated that a comprehensive care plan meeting had not been held for Resident #147; the resident had only been at the facility for six (6) days. During an interview on 5/26/21 at 12:50 p.m. with the Director of Nursing (DON), s/he stated that the baseline care plan should have addressed the behaviors of Resident #147. The DON verified that Resident #147 had behaviors requiring staff to administer [MEDICATION(S)] on the same shift the baseline care plan was developed. The DON verified that the resident arrived at the facility right at shift change for the nurses, but that Resident #147 was having behaviors on the second shift (7 p.m. to 7 a.m.) and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the second shift nurse completed the baseline care plan. The DON stated that the facility did not have a policy or procedure for baseline care plans.

Based on observation and interview the oven and back splash of range were not cleaned per schedule and a kitchen staff member was observed not wearing a beard protector while in the kitchen preparing food. 1 of 1 main kitchen reviewed. The findings included: During initial observation of the main kitchen on 6/10/10 at 9:30 AM with the Dietary Manager, the ovens had dark brown splatters built up on the inside of the ovens. When the Dietary Manager was asked for the cleaning schedule it was revealed that the ovens were supposed to have been cleaned on 6/5/19; however, that employee had been on leave of absence and no one had taken that assignment. The back splash behind the range top also had build-up of dark brown splatters. On 6/12/19 at 11:45 AM the Chef was observed working over food with no beard protector in place. This was confirmed by the Dietary Manager.

Based on observations and interviews, the facility failed to ensure that residents' personal laundry was processed to an appropriate manner. The laundry room large overhead vent near the front of the washer was noted with a heavy build of gray matter. There was large section of plastic peeling from the ceiling near the rear of the washer with a hole in the area. Staff did not use a sanitation process of wiping the washer when doing individual residents' laundry. There was no policy in place regarding the handling on resident's personal laundry while at the facility. 1 of 1 laundry rooms reviewed. The findings included: A random observation of the laundry process on 6/11/19 at approximately 7:48 AM with the Linen Service worker revealed a single stainless-steel washer with multiple streaks on the outside of the washer. A large overhead vent near the front of the washer was noted with a heavy buildup of gray matter. There was a large section plastic peeling from the ceiling behind the washer with a hole in the area. The laundry staff did not wipe the washer with a sanitation process after washing individual residents clothing. All the residents clothing was transported in a clear thin plastic bag. Residents identified as being on contact precaution laundry was transported in a clear thin plastic bag. During an interview on 6/11/19 at approximately 8:08 AM with the Linen Service Worker s/he confirmed the observation related to the multiple streaks on the outside of the washer, the hole in ceiling with peeling plastic and heavy lint build up. The Linen Service Worker further stated s/he would wipe down the inside and outside of the washer after every two loads of laundry but did not have an training on how often to clean the washer. During an interview on 6/11/19 at approximately 9:27 AM with the Director of Nursing revealed the facility did not have a policy in place regarding washing resident's personal laundry. The facility reportedly uses the universal precaution doctrine but there was no formal guidance in place for laundry staff to follow. During an interview on 6/12/19 at approximately 12:26 PM with the Housekeeping Manager revealed there was no documentation of training provided to laundry staff on how to maintain the laundry area when handling resident's personal laundry. And no documentation of training when handling resident's laundry who were identified as being on contact precautions such as C.diff ([MEDICAL CONDITION]) or MSRA (Methionine Sulfoxide Reductase A). The Housekeeping Manager further stated that all residents' clothes are transported to the laundry in clear plastic bag. There was no distinction between a resident on contact precautions or the other residents clothing process.

Based on observations and interviews, the facility failed to provided dignity during the dining experience on 1 of 3 halls observed and 1 of 1 main dining room observed. Residents that depended on staff to feed them were not served and eating while their roommate was served and eating in full view of the resident not served or eating on the hall with room numbers 33 through 46. Staff was observed placing clothing protectors on residents in the main dining without asking. The finding included: During a random meal observation on 6/10/19 at approximately 12:45 PM revealed a resident served and eating independently in rooms [ROOM NUMBERS] while their roommate was in the room not served or eating in full view of the resident that was eating. During an interview and observation with the Director of Nursing (DON) on 6/10/19 at approximately 12:55 PM s/he confirmed that residents that can feed themselves independently are served first and the residents that require staff assistance are served and fed last when staff are available. The DON further acknowledged the privacy curtains were not pulled and the resident that was eating was in full view of the resident waiting to be served. During a dining room observation on 06/10/19 at approximately 12:00 PM, CNA #1 was in the main dining room assisting residents. CNA #1 applied clothing protectors to residents #57, #40 and #7 without asking permission. During an interview with CNA #1 on 06/10/19 at approximately 12:40 PM CNA #1 stated I just know they want one and they do (want one) when I ask.

Based on observation and interview the facility failed to ensure medications were not expired. 2 of 2 medication storage rooms reviewed. The findings included: On 06/11/19 at approximately 09:28 AM surveyor was performing medication storage and discovered expired [MEDICATION NAME] (5 mls/300 mg). The expired [MEDICATION NAME] sulfate was packaged in individual doses of 5 milliliters. 50 individual dosages of the expired medication was dated as expiration date (MONTH) 2019. In addition, 20 individual dosages of the expired medication was dated as expiration date (MONTH) (YEAR). On 06/11/19 at approximately 09:28 AM the Unit Manager and Pharmacist were present during the medication storage checking for expired medications and confirmed the expired medications and removed the expired medications.

Based on observations and interview, the facility failed to ensure that privacy curtains in rooms near the window provided full privacy. The privacy curtains in rooms 34-B, 35-B, 36-B, 45-B and 46-B did not extend from wall to wall to ensure full privacy, had stains or tears. 1 or 3 halls reviewed. The findings included: Random room observations on 6/10/19 at approximately 10:41 AM revealed the privacy curtain near the window in rooms 34-B, 35-B, 36-B, 45-B and 46-B did not extend from wall to wall to provide full privacy, had stains or in poor repair (tears). During an interview and observation with the Housekeeping Manager on 6/10/19 at approximately 11:05 AM s/he confirmed there were privacy curtains that did not extend from wall to wall near the window. The Housekeeping Manager stated the facility was in the process of replacing worn and stained privacy curtains. When asked if there was documentation to indicate the facility had identified the concerns with the privacy curtains; the Housekeeping Manager stated no. At approximately 11:20 AM on 6/10/19, the housekeeping department provided a list of rooms #26, #27, #34, #35, #36, #37, #38, #41, #45, #46, #48, #51 and #54 with a note that indicated need to order. No further information was noted.

Based on record review and interview Resident #29 had no resident assessment done after readmission to the facility related to pressure ulcer developed in the hospital. 1 of 4 residents reviewed for pressure area. The findings included: The facility admitted Resident #29 on 4/26/19 with [DIAGNOSES REDACTED]. Review of Resident #29's Physicians orders revealed an order to clean wound to right hip with wound cleanser and prep area with skin prep, apply therahoney gel and cover with dry dressing daily and PRN(as necessary). Review of Resident #29's Nurses note dated 5/23/19 documented skin condition fair with redness on buttocks, open pressure area on right hip, standing orders applied (therahoney to right hip.) Record review of Resident #29's record revealed that a MDS (Minimum Data Set) had not been completed since re-admission. Review of Resident #29's Care Plan on 6/12/19 revealed no care plan addressing the pressure ulcer. During an interview with the Director of Nursing (DON) on 6/12/19 the DON stated that s/he had not assessed Resident #29 for pressure ulcers when the resident returned from the hospital. Therefore, the pressure area had not been staged or measured, and no documentation had been done on the wound since 5/23/19.

Based on record review and interview an initial care plan problem for pressure area was never added to the care plan when Resident #29 returned from the hospital. 1 of 4 care plans reviewed for pressure areas. The findings included: The facility admitted Resident #29 on 4/26/19 with [DIAGNOSES REDACTED]. Review of Resident #29's Physicians orders revealed an order to clean wound to right hip with wound cleanser and prep area with skin prep, apply therahoney gel and cover with dry dressing daily and PRN(as necessary). Review of Resident #29's Nurses note dated 5/23/19 documented skin condition fair with redness on buttocks, open pressure area on right hip, standing orders applied (therahoney to right hip.) Record review of Resident #29's record revealed that a MDS (Minimum Data Set) had not been completed since re-admission. Review of Resident #29's Care Plan on 6/12/19 revealed no care plan addressing the pressure ulcer. During an interview with the Director of Nursing (DON) on 6/12/19 the DON stated that s/he had not assessed Resident #29 for pressure ulcers when the resident returned from the hospital. Therefore, the pressure area had not been staged or measured, and no documentation had been done on the wound since 5/23/19. During an interview with the Care Plan Co-coordinator on 6/12/19 s/he stated that the care plan was not updated to reflect the pressure area because it had not been assessed as a wound. The Care Plan Co-coordinator stated that s/he usually picks up in daily meetings or wound assessments. S/he also stated the physicians order for treatment was missed. Review of Resident #29's Medication Administration and Treatment Administration Sheets were reviewed, and treatments were documented as done daily to the pressure area on the right hip. Observation of wound care on 6/12/19 at 3:30 PM showed the wound to be clean, no drainage, and healing.

Based on interview and record review the facility failed to act on grievances of the resident council for 3 to 5 months of concerns. The resident council filed concerns of call lights and response times that the facility failed to address in a timely manner. The findings included: Review of resident council minutes on 6/25/18 at approximately 1:22 PM revealed concerns of call light response times and staff taking call lights from residents for (MONTH) and (MONTH) of (YEAR). Interview with resident council on 6/25/18 at approximately 2 PM revealed staffing issues are ongoing and that it can still take time for staff to respond to call lights. Some of the residents expressed having wet themselves because staff were taking too long to respond to call lights. They expressed this issue had been going on for approximately 5 months. Review of grievance logs on 6/27/18 at approximately 10:50 AM revealed concerns with call bell response times going back since (MONTH) (YEAR).

Based on record review and interview, the facility failed to maintain sufficient staffing to provide care and services to the residents for 4 of 4 units reviewed during the survey. The findings included: Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's grievance log from January-June (YEAR) on 6/26/2018 at approximately 930AM revealed that there was an ongoing issue with call-light response time since (MONTH) (YEAR). The Resident Council minutes for the same period were also reviewed and proved that call light response was an ongoing issue since (MONTH) (YEAR). In a telephone interview with Resident 19's Responsible Party (RP), RP stated that it could take up 30 minutes for the facility staff to answer the call light. The RP also stated that when staff did respond after waiting, staff would verbalize to him/her that it took so long to respond because the facility was short staffed. In an interview with the Director of Nursing (DON) regarding a different resident on 6/26/2018 at 11AM, the DON stated, the splints haven't been applied because we probably had staffing issues on those days and didn't have anyone to place them. Review of resident council minutes on 6/25/18 at approximately 1:22 PM revealed concerns of call light response times and staff taking call lights from residents for (MONTH) and (MONTH) of (YEAR). Interview with resident council on 6/25/18 at approximately 2 PM revealed staffing issues are ongoing and that it can still take time for staff to respond to call lights. Some of the residents expressed having wet themselves because staff were taking too long to respond to call lights. They expressed this issue had been going on for approximately 5 months. Review of grievance logs on 6/27/18 at approximately 10:50 AM revealed concerns with call bell response times going back since (MONTH) (YEAR). Interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 6/27/18 at approximately 9:20 AM revealed s/he watches over 30 residents and does not have enough time in a shift to finish tasks without sacrificing breaks or staying late. S/he also stated that the facility is aware with staffing problems and short staffing, and they try to get people to work overtime and are trying to hire new staff. Interview with Certified Nursing Assistant (CNA) #1 on 9:30 AM confirmed concerns with staffing. S/he stated that nurses, restorative, and activities staff are often pulled onto units to help out. Interview with Director of Nursing (DON) on 6/27/18 at approximately 9:55 AM confirmed that staff from activities and restorative staff are pulled a couple times a week to work as a CNA. Interview with Staffing Coordinator on 6/27/18 at approximately 10 AM revealed turnover rate was high. Review of Turnover Report on 6/27/18 at approximately 10:30 AM revealed a 20% turnover rate for skilled nursing care over the period of a year.

July 17, 2012 - Ammended to reflect change of original Scope and Severity Lowered to "K" and lowered Scope and Severity to "E" On the days of the Recertification and Extended Survey, based on observations, record review, and interviews, the facility failed to ensure the staff monitored visitors/sitters interactions with residents to ensure the safety and well being of residents in the facility. Resident #18 was allegedly verbally abused by Resident #11's visitor/sitter. The findings included: Cross refers to F-226 as it relates to the failure of the facility to follow policy to identify abuse and neglect, report allegations of abuse/neglect as well as protect residents from further abuse/neglect once an allegation was reported. Cross refers to F-490 as it related to the failure of the facility Administration to provide the necessary oversight to ensure policies and procedures related to protecting residents from abuse/neglect by reporting and intervening to prevent further abuse/neglect was implemented properly. The Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures and met regulatory requirements. Cross refers to F-520 as it relates to the failure of the facility to be aware that paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures. The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review revealed an Annual MDS (Minimum Data Set) dated 6/17/11 that indicated the resident had a BIMS (Brief Interview for Mental Status) of 3 indicating she was cognitively impaired. Review of the MDS dated [DATE] indicated Resident #18 had long and short-term memory with severe cognitive impairment in daily living skills. The MDS further indicated the resident had the ability to respond adequately to simple direction; no behavior problems were noted. On 5/01/12 at approximately 4 PM this surveyor heard loud yelling on the Gaston Unit. At least four staff members were observed on the unit at the time of yelling. As the surveyor approached the room from which the yelling was coming, she observed a tall, large male, believed to be a family member of Resident #11, standing over, yelling and pointing his finger at Resident #18 who was seated in a Geri chair. The male looked directly at Resident #18 and stated, "You don't talk to her. You don't say anything to her. You all better move her." Prior to the surveyor approaching the room a hospice nurse was observed standing outside the door while the family member yelled at Resident #18. The surveyor in the hallway observed four facility staff members, fail to respond to the family member yelling at Resident #18. The surveyor approached the staff in the hallway and asked, "Can anyone hear the yelling going on down the hall? What are you going to do about the family member yelling at the resident?" The staff looked at the surveyor and hesitated. CNA (Certified Nursing Assistant) #3 entered the room and the family member and Resident #11 exited the room. The nurse at the medication cart did not attempt to protect Resident #18 from the angry family member. At approximately 4:08 PM the surveyor overheard Licensed Practical Nurse (LPN) #1 asking Registered Nurse (RN) #1 "What should I do? Should I write a report?" The State Agency surveyor reported to the Administrator at 4:35 PM on 5/01/12 the staff 's failure to respond immediately to protect Resident #18 from the alleged family member. In addition, the family member/sitter that was observed verbally abusing Resident #18 was allowed by staff to remove Resident #11 from the room via wheelchair and go to an unsupervised area of the skilled nursing facility without intervention by staff. In an interview with the surveyor on 5/02/12 at approximately 3:35 PM CNA #1 stated Resident #18 was confused and always made statements like "This is my house." The CNA stated the visitor had been observed having conversations with himself but that 5/01/12 was the "first time I have seen him in this rage." CNA #1 stated the visitor was loud and had been observed fussing with the staff last week. She stated that she did not respond to the yelling because the visitor was generally loud. The surveyor interviewed CNA #3 at approximately 3:50 PM on 5/02/12; she stated that she did not pay attention to the visitor's loud talking because he generally spoke loudly. In an interview with the surveyor on 5/02/12 at approximately 4:05 PM RN #1 stated the visitor was generally loud and "sometimes he would get upset about clothes." In an interview with the surveyor on 5/02/12 at 8:30 AM the Administrator stated he was not aware of the Elder Justice Act (Affordable Care Act 2012), which requires long-term care facilities to report any reasonable suspicion of crimes. On 5/2/12 at 5:05 PM the Administrator stated the visitor was not a family member but a private sitter. The Administrator stated he was unaware the visitor was not a relative until today. The facility had no policy and procedures in place related to paid sitters and their role in the facility. On 5/2/12 at 1:55 PM, the Administrator and the Director Of Nursing were notified of a second Substandard Quality of Care and/or Immediate Jeopardy existing in the facility when an observation was made of a visitor verbally abusing a resident with no staff intervention to protect the resident. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and facility procedures. The Administrator was informed of this on 5/3/12. The citation at F-223 remained at a lower scope and severity of "E".

July 17, 2012 - Ammended to reflect change to original Scope and Severity to "J" and lowered Scope and Severity to "D" On the days of the Recertification and Extended survey, based on record reviews, interviews and incident logs, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Application of heat by a licensed staff member to the leg of Resident #11, 1 of 3 residents reviewed for heat treatments, was applied improperly and not monitored resulting in a second degree burn to the resident. The incident was not reported as possible neglect to the State Agency. The findings included: Cross refers to F-226 as it relates to the failure of the facility to follow policy to identify neglect, report allegations of neglect as well as protect residents from further neglect once an allegation was reported. Cross Refers to F-281 as it relates to the failure of the facility Nursing staff to verify the physician's orders [REDACTED]. The failure placed Resident #11 at risk of serious harm. Cross Refers to F-323 as it relates to the failure of the facility to provide necessary care for Resident #11 when a licensed staff member used a microwave to heat a compress and placed the heated compress directly on the resident's leg without using a barrier between the resident's leg and the compress. This action resulted in a second degree burn to the resident's leg. Cross Refers to F-490 as it relates to the failure of the Administrator to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administrator was aware that a licensed nurse used a microwave to heat a compress and apply it directly to a resident's leg that resulted in a second degree burn and failed to implement corrective action to ensure resident safety. Cross Refers to F-520 as it relates to the failure of the facility to ensure that the Quality Assurance process was utilized to identify, monitor and implement a plan of correction related to an injury that was the result of applying heat to a resident incorrectly. The facility admitted Resident #11 on 11/18/2011 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders (TO) revealed that Resident #11 had a TO (telephone order) dated 3/11/12 for "Heat to knee" and a clarification order on 3/11/12 for heat to knee q (every) shift. On 3/27/12 a new TO was written to D/C (discontinue) heat to left knee and orders were given for a treatment to the knee. Review of the facility's Event Report indicated that on 3/27/12 at 10:30 AM the nurse was "called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'." On 5/2/2012 at 9:05 AM, during an interview with the Assistant Director of Nursing (ADON), she stated the incident had not been reported because the injury was not of unknown origin and the facility did not feel like the nurse intended to cause harm to the resident. On 5/3/2012 at 10:30 AM, the Administrator, Director of Nursing and the Assistant Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy were identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment, which was executed and applied incorrectly. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of abuse policies and procedures and the proper use of heat treatments. The Administrator was informed of this on 5/3/12. The citation at F-225 remained at a lower scope and severity of "D".

July 17, 2012 - Ammended to reflect change to original Scope and Severity to "K" and lowered Scope and Severity to "E" On the days of the Recertification and Extended survey, based on interviews, record reviews, and review of the facility Abuse and Neglect Policy the facility failed to follow its policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The facility staff failed to report neglect involving Resident #11 who suffered a burn related to a heat treatment which was applied incorrectly. The incident was not investigated and reported to the State Agency. The facility staff failed to respond when a sitter for Resident #11 yelled at her roommate Resident #18; multiple staff members were observed by the surveyor standing by when the incident occurred. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Resident #18 was allegedly verbally abused by Resident #11's visitor/sitter. Cross Refers to F-225 as it relates to the failure of the facility to report and thoroughly investigate an incident in the facility as possible neglect due to a nurse's inappropriate approach to applying heat to Resident #11's leg that resulted in a burn. Cross Refers to F-281 as it relates to the failure of the facility Nursing staff to verify the physician's orders [REDACTED]. The failure placed Resident #11 at risk of serious harm. Cross Refers to F-323 as it relates to the failure of the facility to provide necessary care for Resident #11. The resident was burned when a nurse used a microwave to heat a compress and placed it directly on the resident's leg without using an appropriate barrier between the resident's leg and the heated compress. This action resulted in a second degree burn to the resident's leg. Cross Refers to F-490 as it relates to the failure of the Administrator to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administrator was aware that a licensed nurse used a microwave to heat a compress and apply it to a resident's leg that resulted in a second degree burn and failed to implement corrective action to ensure resident safety. In addition, the Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures. Cross Refers to F-520 as it relates to the failure of the facility to ensure that the Quality Assurance process was utilized to identify, monitor and implement a plan of correction related to an injury that was the result of applying heat to a resident incorrectly. In addition, the Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures and met regulation. The facility admitted Resident #11with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders (TO) reveled that Resident #11 had a TO (telephone order) dated 3/11/12 for "Heat to knee" and a clarification order on 3/11/12 for heat to knee q (every) shift. On 3/27/12 a new TO was written to D/C (discontinue) heat to left knee and orders were given for a treatment to the knee. Review of the facility's Event Report indicated that on 3/27/12 at 10:30 AM the nurse was "called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'." On 5/2/2012 at 9:05 AM, during an interview with the Assistant Director of Nursing (ADON), she stated the incident was not reported because the injury was not of unknown origin and the facility did not feel like the nurse intended to cause harm to the resident. No further investigation was done by the facility. The facility admitted Resident #18 on 6/10/11 with [DIAGNOSES REDACTED]. On 5/01/12 at approximately 4 PM the surveyor heard loud yelling on the Gaston Unit. At least four staff members were observed on the unit at the time of yelling. As the State Agency surveyor approached the room from which the yelling was coming, she observed a tall, large male, believed to be a family member of Resident #11, standing over, yelling and pointing his finger at Resident #18 who was seated in a Geri chair. The male looked directly at Resident #18 and stated, "You don't talk to her. You don't say anything to her. You all better move her." Prior to the surveyor approaching the room a hospice nurse was observed standing outside the door while the family member yelled at Resident #18. The surveyor in the hallway observed four facility staff members who failed to respond to the family member yelling at Resident #18. The surveyor approached the staff in the hallway and asked, "Can anyone hear the yelling going on down the hall? What are you going to do about the family member yelling at the resident?" The staff looked at the surveyor and hesitated. CNA (Certified Nursing Assistant) #3 entered the room and the family member and Resident #11 exited the room. The nurse at the medication cart did not attempt to protect Resident #18 from the angry family member. Review of the facility's "Policy & Procedure Manual Subject: Abuse and Neglect" last revised on July 2010 stated, "Policy: ...Failure to report shall be cause of disciplinary action... All allegations will be reported to appropriate agencies and services as required by applicable state and federal regulations. The DHEC Certification Division shall be notified within 24 hours of the allegation... Procedure: ... 1. Any person having information, either by direct observation or by report, or any act or suspected act that he/she considers may be abuse, neglect or mistreatment of [REDACTED]. Initial reports are to be completed verbally and in a written form on an Incident Report. This Incident Report should be given immediately or as soon as practically possible to the Health Facility Administrator, the Director of Nursing, or his/her designee. The Health Facility Administrator... will initiate an Investigation. 2. Any employee who reports or who receives a report of abuse or neglect must take whatever actions are appropriate to protect the resident from further alleged abuse or neglect. 3. The resident's physician and agent will be notified... A resident who is a victim of alleged abuse or neglect must be immediately assessed by a Licensed Nurse... The clinical record of the resident for whom a suspected abuse/neglect report is completed must contain objective information, facts NOT speculation. 4. The investigation Report is considered a confidential facility report and should include: a. The date, time, location of the alleged incident; b. A complete description of the event... e. A description of any injuries sustained and/or any changes in resident's mental state... h. Action taken... 6. If a family member or other visitor is suspected of abuse, they may not be allowed to visit the resident, or may be required to visit only if a staff member is present... 8. The results of all investigations of substantiated incidents of abuse or neglect will be reported to the Department of Health Licensing and Certification and to all other agencies in accordance with state law within five (5) working days... DEFINITIONS 1. "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or the deprivation by care custodian of goods or services that are necessary to avoid physical harm or mental suffering... 3. "Verbal" refers to any use of oral, written or gestured language that includes disparaging and derogatory term to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability... 15. "Neglect" means failure to exercise that degree of care which a reasonable person in a like position would exercise. It includes failure to assist in personal hygiene or the provision of food and clothing, failure to provided medical care for physical and mental health needs, failure to protect from health and safety hazards... Reporting/Response: ...All substantiated incidents of abuse or neglect will be reported to the Quality Assurance Committee..." On 5/3/12 at 10:30 AM, the Administrator, Director of Nursing, and the Assistant Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment which was executed and applied incorrectly. On 5/2/12 at 1:55 PM, the Administrator and the Director Of Nursing were notified of a second Substandard Quality of Care and/or Immediate Jeopardy existing in the facility when an observation was made of a visitor verbally abusing a resident with no staff intervention to protect the resident. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and facility procedures. The Administrator was informed of this on 5/3/12. The citation at F-226 remained at a lower scope and severity of "E".

July 17, 2012 - Ammended to reflect changes to the original Scope and Severity to "K" and lowered Scope and Severity to "E". On the days of the Recertification and Extended survey, based on record reviews, interviews and review of facility policy and procedures related to providing heat treatments, the facility administration failed to effectively and efficiently utilize resources to prevent one of one sampled resident from harm due to inappropriate application of a warm compress treatment. The facility failed to obtain clarification orders related on how to apply heat to a resident and failed to monitor the treatment which resulted in a burn to a resident. The facility failed to complete a thorough investigation of the burn incident and failed to report the injury as neglect to the State survey and certification agency. In addition the facility failed to develop policies on using paid sitters in the facility and were unaware of sitters currently working in the facility at the time of survey. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Cross Refers to F-225 as it relates to the facility's failure to report an allegation of neglect to the State survey and certification agency. Cross Refers to F-226 as it relates to the facility's failure to ensure that staff was adequately trained to define, recognize and report allegations of abuse/neglect. Cross Refers to F-281 as it relates to the facility's failure to ensure that the licensed staff received adequate training to request clarification orders on applying a warm compress treatment and the monitoring of the treatment to prevent injury. Cross Refers to F-323 as it relates to the facility failure to prevent accidents and hazards for a resident that was burned during a warm compress treatment. Cross Refers to F-520 as it relates to the facility's failure to ensure each resident receiving warm compress treatments was adequately and accurately assessed for burns/injury due to warm compress treatments. The systemic failure of the facility to identify, accurately assess, and monitor residents receiving a warm compress treatment, after having knowledge a resident in the facility was harmed, placed other residents at risk for additional injury and/or harm. At the time of the survey, there was no evidence that the facility provided training to staff in order to prevent inappropriate heat treatments after a resident was harmed during an incident resulting in a burn noted on 3/27/12. There was no evidence that the incident was thoroughly investigated and reported as possible neglect to the State survey and certification agency. An interview on 5/02/12 at approximately 12:10 PM with the facility Administrator revealed the burn incident was not reported as abuse/neglect because he thought it was an isolated incident. The Administrator stated the facility wrote an incident report and the nurse that performed the treatment incorrectly was released from the nursing home as an employee. The Administrator further stated no re-education of the staff was provided due to the 3/27/12 burn incident. A visitor was observed during the survey yelling at a resident with no staff intervention. It was later learned by the facility that the perpetrator was not a visitor but a paid sitter. The Administrator failed to ensure the safety of residents due to being unaware of private sitters currently working within the facility. The facility had no policies in place related to the private sitters role while in the facility. On 5/2/12 at 10:30 AM, the Administrator and the Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 was noted with a burn from a heat treatment which was executed and applied incorrectly. On 5/02/12 at 1:55 PM, the facility was notified that a second Immediate Jeopardy/Substandard Quality of Care had been identified. The Jeopardy existed on 5/01/12 when a routine visitor at the facility was observed standing over, yelling and pointing his finger at a resident without any facility staff intervening to protect the resident from further abuse. Interviews with licensed nurses, certified nursing assistants, admissions staff, activity staff and other facility staff revealed the visitor talked loud all the time. The three certified nursing assistants and licensed nurse on the unit at the time of the incident stated the visitor generally talked loud and they did not think any thing was wrong. The investigation of the incident found the alleged perpetrator was not a visitor but a sitter for the roommate of the resident allegedly abused. The facility staff were not aware the visitor had been employed by a resident's family and was in the building for that purpose. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments.. The Administrator was informed of this on 5/3/12. The citation at F-490 remained at a lower scope and severity of "E".

July 17, 2012 - Ammended to reflect changes to the original Scope and Severity to "K" and lowered Scope and Severity to "E". On the days of the Recertification and Extended survey, based on record reviews and interviews, the facility failed to develop, implement and monitor an action plan for identified concerns related to a nurse placing a hot compress in a microwave, placing it on a resident's skin without monitoring progression of the treatment and resulting in a second degree burn to the resident. The injury noted on 3/27/12 and no review of current policy or re-education was provided to nursing staff to prevent further injuries related to heat treatments. The facility staff failed to recognize verbal abuse and failed to act to protect the resident at the time the abuse took place. In addition, the facility failed to have any policies on using paid sitters in the facility and were unaware of sitters currently working in the facility at the time of survey. The findings included: Cross Refers to F-223 as it relates to the facility's failure to recognize verbal abuse, protect the resident abused, and have policies in place for paid sitters in the facility. Cross Refers to F-225 as it relates to the facility's failure to report an allegation of neglect to the State survey and certification agency. Cross Refers to F-226 as it relates to the facility's failure to ensure that staff was adequately trained to define, recognize and report allegations of abuse/neglect. Cross Refers to F-281 as it relates to the facility's failure to ensure that the licensed staff received adequate training to request clarification orders on applying a warm compress treatment and the monitoring of the treatment to prevent injury. Cross Refers to F-323 as it relates to the facility failure to prevent accidents and hazards for a resident that was burned during a warm compress treatment. Cross Refers to F-490 as it relates to the failure of the facility's Administration to provide the necessary oversight to ensure policies and procedures related to applying a warm compress was implemented properly. The Administration was aware of the resident's injury due to inadequate treatment since 3/27/12. An interview on 5/02/12 at approximately 12:10 PM with the Administrator revealed no in-services were provided related to the nurse's failure to get a clarification order in applying a heating treatment and monitoring the treatment. The Administrator stated no in-services/re-education was provided to the nursing staff after the 3/27/12 burn incident because it was an isolated incident. The Administrator acknowledged no Performance Improvement Plan was put in place after the incident. In addition, Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures. On 5/2/12 at 10:30 AM, the Administrator and the Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 was found with a burn from a heat treatment which was executed and applied incorrectly. On 5/02/12 at 1:55 PM, the facility was notified that a second Immediate Jeopardy/Substandard Quality of Care had been identified. The Jeopardy existed on 5/01/12 when a routine visitor at the facility was observed standing over, yelling and pointing his finger at a resident without any facility staff intervening to protect the resident from further abuse. Interviews with licensed nurses, certified nursing assistants, admissions staff, activity staff and other facility staff revealed the visitor talked loud all the time. The three certified nursing assistants and licensed nurse on the unit at the time of the incident stated the visitor generally talked loud and they did not think any thing was wrong. The investigation of the incident found the alleged perpetrator was not a visitor but a sitter for the roommate of the resident allegedly abused. The facility staff were not aware the visitor had been employed by a resident's family and was in the building for that purpose. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments.. The Administrator was informed of this on 5/3/12. The citation at F-520 remained at a lower scope and severity of "E".

On the days of the Recertification and Extended survey, based on observations, interviews, record reviews and review of the facility's policies entitled Applying A Warm Compress Or Soak and Standing Orders for Chester Regional Nursing Center, and the facility Event Report, the facility failed to provide services that met professional standards of quality for 3 of 16 sampled residents reviewed for professional standards of care. Resident #11 received a burn due to improper application by a licensed staff member, failure to monitor the heat treatment, and failure to consistently assess and monitor healing of the burn, Resident #16 with a low body temperature reading had no recheck of temperature delaying treatment, and the facility allowed untrained Licensed Practical Nurses (LPN) to administer medications through a Peripherally Inserted Central Catheter (PICC) or did not have a Registered Nurse present in the facility during the medication administration via the PICC line for Resident #1. The findings included: Cross Refer to F323 as it relates to a licensed staff member applying heat improperly to Resident #11 resulting in a second degree burn to the resident's leg. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. On 5/1/2012 at 3:40 PM, during review of the medical chart for Resident #11, a telephone order dated 3/11/12 indicated that the resident had an order for [REDACTED]. There were no orders noted to indicate which type of heat was to be used, moist or dry. The Nurse's Notes (NN) dated 3/8/12 indicated that the resident had complained of left knee pain and a pain medication was given. On 3/11/12 the NN again indicated that the resident had left knee pain and the physician was in the facility and ordered heat to the knee every shift. The NN contained no documentation related to clarifying the order for moist or dry heat. The Treatment Record indicated that heat was applied to the resident's knee every shift as ordered until it was discontinued on 3/27/11. The NN for 3/27/12 at 11:00 AM revealed that the facility received new orders to discontinue the heat to the resident's left knee and an order for [REDACTED]. On 3/28/12 at 10:00 AM, the NN stated that blisters and redness were noted. On 3/29/12 at 2:30 PM the NN indicated that an increase in the size of the blisters was noted and that the blisters were intact. On 3/29 at 5:00 PM the nurses documented "continue to monitor. dressing dry and intact" and on 3/30 12 at 1:45 AM, "dry and intact". On 4/1/12, 4/3/12, 4/4/12 and 4/7/12 the Nurse's Notes indicated that the dressing was dry and intact. On 4/14/12 at 1:00 PM a new order was received to change the treatment to Resident #11's left knee. On 4/15/12 at 10:00 AM the nurses documented that the physician was in to see Resident #11. No other NN related to the left knee were noted. The Nurse's Notes contained no measurement of the blisters or how many blisters were present. During the survey on 5/1/12 at 3:50 PM, LPN #1 removed the resident's knee dressing. The area of the resident's knee cap was discolored and purple. Three areas were noted on the knee, 1 area was approximately 1 inch long by 1/2 inch wide, 1 was approximately 1/2 by 1/2 inches and 1 was approximately 1/4 by 1/4 inches. There were no intact blisters observed on the knee. All 3 areas contained sloth in the wound bed and all 3 were bright red in color around the sloth. No odors were noted. Further review of the resident's record revealed no documentation in the Physician's Progress Notes related to the burn. The facility's skin sheets were also reviewed. The skin sheet had documentation on 3/31/12 that blisters were present-treatment in progress, on 4/14/12: left knee blisters, treatment in progress bandage intact, on 4/21/12- left knee in progress and a skin sheet with no date stated that left knee wound treatment was in progress. The skin notes contained no entries related to Resident #11's knee wound. In an interview with Registered Nurse (RN) #1, she verified that there were no other places where wound/skin notes were documented and that there was no documentation of measuring the knee wounds. Review of the facility's Event Report indicated that on 3/27/12 at 10:30 AM the nurse was "called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'." In an interview on 5/2/12 at 9:05 AM with the Assistant Director of Nursing (ADON), the ADON stated that the facility uses moist heat unless the physician orders heat packs but the order should have been clarified as to which type of heat to use. When asked if the treatment should have been checked and documented every 5 minutes as written in the policy for moist heat, the ADON stated that the facility does not have check sheets but if the policy indicates every 5 minute checks they should have been done and documented. When asked if it was normal practice at the facility to heat moist cloths in the microwave for heat treatments, the ADON stated that it was not the normal practice to use a microwave. On 5/2/12 from 9:30 AM to 9:42 AM, 4 nurses were interviewed related to how to use heat for a treatment. RN #2 stated that she would use a heat pack wrapped in a towel. LPN #4 stated she would call the physician to verify the type of heat source to use. LPN #5 stated she would use a heat pack and LPN #6 stated that she would warm moist cloths in the microwave. In an interview on 5/2/12 at 12:35 PM, the physician stated that he was informed of the incident stating it was a burn "2nd degree." The physician stated that he would expect the nurses to use moist heat when he ordered heat. He stated that he would expect the wound nurse to monitor, measure and document the progression of blisters, pressure ulcers and surgical sites. He also stated that he would expect the facility to in-service the staff after any incident. Review of the facility's policy entitled Applying A Warm Compress Or Soak indicated "...Preparation 1. Verify that there is a physician's order for this procedure...2. Check the resident's skin often. Look for: a. Too much redness b. Skin discoloration...Equipment and Supplies...4. If applying a warm compress:... c. Pitcher of warm water (115 degrees F)...k. Unless otherwise instructed, check the skin of the limb being soaked every five (5) minutes..." Resident #1 was admitted with [DIAGNOSES REDACTED]. Record review on 4/30/12, at approximately 12:15PM, revealed an admitting Physician's order for Flush PICC (Peripherally Inserted Central Catheter) line with NS (Normal Saline) 5 ml (milliliters) prior to and after med (medication) administration. Further review revealed a Physician's order dated 4/17/12 to D/C (Discontinue) PICC line. Review of the April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 4/30/12 with the Gaston Unit Manager indicated that all the nurses who signed off as doing the PICC line flushes were Licensed Practical Nurses (LPN). Review of "The South Carolina State Board of Nursing Advisory Opinion #28 Revision" revealed that the Board of Nursing for South Carolina acknowledges it is within the extended role practice of the selected LPN to perform procedures and to administer ordered treatments via peripheral and central venous access devices and lines according to the following stipulations: "2. LPN's must complete specialized education and training relative to arterial and central access lines. A registered nurse must be immediately available for supervision." Review of the Facility's Policy# B-261 titled "Picc (Peripherally Inserted Central Catheter)" states under "III. RESPONSIBILITY, A. Nursing:, 2. The special selected LPN must complete an intravenous therapy course relative to the administration of fluids and medications via peripheral and central venous access devices and perform the necessary skills checklist. These skills will be performed under the immediate availability and supervision of a Registered Nurse." Interview on 5/1/12, at approximately 3:00pm, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed three of the LPNs who signed off as doing the PICC line flushes did not have the required specialized education and training. In addition, during review of the daily nursing staffing sheets for 4/6/12 through 4/17/12 when the PICC line was discontinued, the DON and ADON confirmed that for eleven of thirty-three shifts reviewed there was no registered nurse immediately available for supervision. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 5/01/12 revealed nurse's notes dated 4/12/12 at 1:45 PM that stated: "resident alert and verbal with respiratory even and unlabored no distress noted". A nurse note dated 4/13/12 at 4 AM "vital sign 97 Temperature, 98 Pulse, 20 Respiration with 104/76 Blood Pressure." Nurse note (NN) dated 4/13/12 at 7 PM indicated resident "alert with nasal cannula. Assisted with all activities of daily living (ADLs), no sign and symptom of pain or distress". NN dated 4/14/12 at 1:30 AM indicated vital signs "125/68 Blood Pressure, 81 Pulse, 98.8 Temperature, 20 Respiration. No sign and symptom of distress with breathing even and unlabored. Resting quietly with continue to monitor." NN dated 4/14/12 at 10 AM indicated "noted increased foul smelling drainage from left hip wound. Medical Doctor on call with new orders for C&S (culture and sensitivity) [MEDICATION NAME] 500 mg every day for 7 days". NN dated 4/14/12 at 5:15 PM "vital sign 92 Temperature, 60 Pulse, 20 Respiration, 90/62 Blood Pressure with resident resting quietly in bed at present. Noted to be alert with confusion. No complaints voiced and requires total care with ADLs." NN dated 4/15/12 at 12 Noon indicated resident was "alert, non verbal and denies pain with Respiration up 28, no Blood Pressure reading, 64 Pulse, Temperature of 90 with no oxygen statistics. Finger nails noted to be purple and hands very cold to touch with Medical Doctor called." NN dated 4/15/12 at 12:40 PM "Resident transported to emergency room ." An interview on 5/03/12 at approximately 1:30 PM with the Assistant Director of Nursing (ADON), after reading the nurses' notes dated 4/12/12 to 4/15/12 the ADON stated 02 should have been started and that the facility has standing orders as to when to provide oxygen and notify the physician. On 5/2/12 at 10:30 AM, the Administrator and the Director Of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment which was executed and applied incorrectly. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments.. The Administrator was informed of this on 5/3/12. The citation at F-281 remained at a lower scope and severity of "D".

On the days of the Recertification and Extended survey, based on observations, interviews, record reviews and review of the facility's policy's entitled Applying A Warm Compress or Soak, Event Report, and Abuse and Neglect, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed for burns. Resident #11 received a burn when a heat treatment was administered incorrectly and not monitored during the treatment. In addition 3 of 4 units were noted to have high hot water temperatures and one of 4 units was noted to have low cool water temperatures. The findings included: Cross Refer to F281 as it relates to the facility failure to ensure resident treatments were performed safely and failure to consistently assess and monitor progress should any harm occur. The facility admitted Resident #11 on 11/18/2011 with [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed a facility's Event Report that indicated on 3/27/12 at 10:30 AM the nurse was "called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'." Further documentation reviewed at the facility did indicate the LPN did not check the progress of the treatment after she became busy with other tasks. In an interview on 5/2/12 at 9:05 AM with the Assistant Director of Nursing (ADON), she stated that the facility uses moist heat unless the physician orders heat packs but the order should have been clarified as to which type of heat to use. When asked if the treatment should have been checked and documented every 5 minutes as written in the policy for moist heat, the ADON stated that the facility does not have check sheets but if the policy says every 5 minute checks they should have been done and documented. When asked if it was normal practice at the facility to heat moist cloths in the microwave for heat treatments, the ADON stated that it was not the normal practice to use a microwave. On 5/2/12 from 9:30 AM to 9:42 AM, 4 nurses were interviewed related to how to use heat for a treatment. RN #2 stated that she would use a heat pack wrapped in a towel. LPN #4 stated she would call the physician to verify the type of heat source to use. LPN #5 stated she would use a heat pack and LPN #6 stated that she would warm moist cloths in the microwave. In an interview on 5/2/12 at 12:35 PM, the physician stated that he had been informed of the incident stating it was a burn "2nd degree.". The physician stated that he would expect the nurses to use moist heat when he ordered heat. He stated that he would expect the wound nurse to monitor, measure and document the progression of blisters, pressure ulcers and surgical sites. He also stated that he would expect the facility to re-train/in-service the staff after any incident. Review of the facility's policy entitled Applying A Warm Compress Or Soak indicated "...Preparation 1. Verify that there is a physician's order for this procedure...2. Check the resident's skin often. Look for: a. Too much redness b. Skin discoloration...Equipment and Supplies...4. If applying a warm compress:... c. Pitcher of warm water (115 degrees F)...k. Unless otherwise instructed, check the skin of the limb being soaked every five (5) minutes..." During the initial tour of the facility on 4/30/12 at approximately 10:45 AM, it was noted the hot water temperature in rooms #22 and #31 on Hall 1 were excessively hot to the touch. The surveyor checked random rooms at approximately 12:20 PM on 4/30/12 with a digital thermometer and the following temperatures were revealed: Room # 29: 122.0 degrees Fahrenheit Room #58: 127.5 degrees Fahrenheit Room #54: 122.4 degrees Fahrenheit Room #20: 122.5 degrees Fahrenheit Room #33: 123.5 degrees Fahrenheit Room #43: 124.3 degrees Fahrenheit On 4/30/12 at approximately 1:50 PM, the surveyor toured with Maintenance Technician #1, the following areas and temperature results were noted as: Hall #1 Shower room sink: 123.0 degrees Fahrenheit Room #26 124.5 degrees Fahrenheit Room #20 125.6 degrees Fahrenheit Room #30 123.0 degrees Fahrenheit Hall #2 Shower room sink: 124.3 degrees Fahrenheit Room #45 123.2 degrees Fahrenheit Room #36 125.7 degrees Fahrenheit Room #38 126.1 degrees Fahrenheit Hall #3 Room #55 128.1 degrees Fahrenheit Room #52 120.0 degrees Fahrenheit Room #59 127.9 degrees Fahrenheit Room #54 122.9 degrees Fahrenheit During an interview with Maintenance Technician #1 on 4/30/12 at approximately 1:50 PM, the Maintenance Technician #1 confirmed he did not know if water temperature checks were routinely performed in residents rooms. On the same day at approximately 2:48 PM, an interview with the Maintenance Director revealed that no one in the maintenance department had checked the main domestic supply temperature that morning. He also stated the facility had not been recording random resident room temperatures since December, 2011 and the facility policy was to have the hot water temperatures be at 115 degrees Fahrenheit or less. He confirmed that the temperature at the main domestic supply was 126.3 degrees per computerized recording early this morning. The Maintenance Director stated he had "already turned the steam valve down and will recheck the temperature at the valve and also in the resident rooms throughout the rest of the evening." On 4/30/12 at approximately 3:50 PM, the Maintenance Director stated he checked the actual temperature at the main boiler, recorded at 140 degrees Fahrenheit, and he had reduced the temperature setting to 115 degrees Fahrenheit. Interview with a facility CNA and a resident was held on 4/30/12 at 3:45PM related to the water temperatures. Both stated that whenever the water was used they mixed the cold with the hot to ensure that the temperature was not at a level that a resident would receive a burn. On 4/30/12 at approximately 1:30 PM, during random resident room water temperature checks, the surveyor noted in the Gaston Wing, Room #64, the hot water temperature was 85.1 degrees Fahrenheit. On the same day at approximately 2:27 PM, the resident in this private room stated, "It's always too cold in the shower and my sink." Random hot water temperature checks continued in the Gaston Wing at approximately 2:30 PM and revealed the following temperatures: Room #61 89.0 degrees Fahrenheit Room #64 88.3 degrees Fahrenheit Room #72 93.3 degrees Fahrenheit Room #77 92.8 degrees Fahrenheit On 4/30/12 at approximately 4:30 PM, the surveyor toured the Gaston Wing with Maintenance Technician #1, and revealed the following hot water temperatures: Room #61 88.1 degrees Fahrenheit Room #72 97.1 degrees Fahrenheit Room #77 104.1 degrees Fahrenheit While observing the Maintenance Director checking the hot water temperature in Room #77, the resident of this room questioned, "Is it warm enough to shave now?". The Maintenance Director revealed on 5/1/12 at approximately 8:50 AM that he did not have a policy in place to perform routine water temperatures in resident room to ensure safe and/or comfortable water temperatures. On 5/2/12 at 10:30 AM, the Administrator and the Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment which was applied incorrectly. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments. The Administrator was informed of this on 5/3/2012. The citation at F-323 remained at a lower scope and severity of "D".