Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springdale Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment was involved in inappropriate sexual contact with another resident who had a history of inappropriate behaviors and was cognitively intact. Staff observed the male resident with his genitals exposed while holding the female resident’s wrist/hand in his lap and using her hand during the sexual act. The female resident had impaired judgment and needed redirection, and the facility failed to prevent the contact from occurring.
Failure to Report Resident Elopement: A resident with multiple medical and psychiatric diagnoses had a successful, unwitnessed elopement after exiting through a staff door using a code obtained from a former CNA. Staff found the resident near the facility after he stated he wanted to leave and planned to get a bus ticket, but the event was not documented in nursing notes and was not reported to the State Survey Agency. The DON and Administrator acknowledged the incident was not reported, and the Administrator stated he did not consider it reportable because the resident was in line of sight by an employee.
A resident with diagnoses including heart disease, HF, DM2, anxiety, MDD, and PTSD, and with a care plan identifying elopement risk, successfully exited through a staff door and was found outside near a road after going past the dumpsters. The resident reported obtaining the door code from a former CNA and wanting to leave, while staff gave differing accounts of who saw him and how far he had gone. No nursing notes, clinical assessments, or provider/RP notifications were documented after the elopement.
A resident with vascular dementia and hospice/palliative care orders had a DNR code status documented in physician orders, a telephone order, and a POST form, but the care plan still listed the resident as Full Code. Interviews showed social services was responsible for updating code status, and the SSD acknowledged the care plan may have been a mistake.
Inaccurate narcotic count documentation was found for 2 of 6 medication carts reviewed. On the 100 Hall cart, seven narcotic counts did not match the count sheets, and on the 200 Hall cart, two counts did not match. An LPN said she documented narcotics after finishing the med pass, while another LPN said she was distracted during medication administration. UMs and the DON stated narcotics should be signed out as soon as they are given and verified at shift change.
Medication administration errors exceeded the allowed rate, with 3 errors in 29 opportunities. An LPN failed to prime insulin pens before giving Novolog to one resident and Lantus to another resident, both with DM, and also mixed Miralax in too little water instead of the required amount.
An LPN failed to prime insulin pens before administering Novolog to one resident and Lantus to another resident, despite both residents having diabetes mellitus. The LPN confirmed the pens were not primed and could not confirm that either resident received the correct insulin dose.
Pest Control Program Failed to Prevent Infestation: The facility failed to keep several resident rooms free of pests. Ecolab documentation showed pest activity and bed bugs in a resident room, and surveyors observed a roach crawling in a sanitizer station near a resident bathroom and later saw another roach crawling across a meeting room table. Residents and staff also reported roaches and other bugs in rooms, ceilings, and common areas, and one room was stripped for deep cleaning after a resident reported seeing a roach.
A resident with a history of seizures was admitted with orders for multiple anti-seizure medications, but missed several doses due to pharmacy delivery issues and lack of timely provider notification. The missed doses led to seizure activity requiring hospital transfer. Staff interviews confirmed delays in medication reconciliation and communication, resulting in a significant medication error.
The facility failed to maintain proper sanitation in the kitchen, with observations revealing a sticky, dirty floor and a heavily soiled deep fryer. The cleaning schedule was not consistently followed, as confirmed by the Dietary Manager and Assistant. The Administrator acknowledged the unsatisfactory cleanliness during an inspection.
A facility failed to administer medications timely for six residents, as per physician's orders. A nurse was observed with nine resident profiles indicating late medications, and admitted to being behind all day. The MAR showed significant delays in administering medications like Gabapentin, Carvedilol, and others. The DON stated that staff should notify physicians and families of late medications and monitor residents' responses.
The facility failed to ensure proper infection control practices, including the use of PPE and hand hygiene, for residents under Enhanced Barrier Precautions. Staff did not consistently sanitize equipment between uses, and housekeeping staff neglected PPE protocols. Additionally, the facility did not offer COVID-19 immunization education or track immunization status for some residents, as required by policy.
A resident was admitted with pressure ulcers that were not promptly reported to the physician, delaying treatment. The admitting LPN noted excoriation but did not obtain necessary wound care orders until days later, contrary to facility policy.
The facility failed to thoroughly investigate an altercation between two residents, one with dementia and bipolar disease and the other with schizoaffective disorder and dementia with agitation. After the incident, which involved one resident slapping the other, the facility did not interview other residents present to assess their safety or psycho-social wellbeing. The Social Services Director did not conduct any safety check interviews, contributing to the deficiency.
The facility failed to implement comprehensive care plans for two residents, leading to unmet care needs. One resident, with dysphagia and dementia, did not receive necessary referrals and consultations after a fall. Another resident, requiring dialysis, experienced a lapse in care when a CNA attempted to take blood pressure on the arm with a dialysis fistula, contrary to care plan directives.
The facility failed to conduct care conferences for two residents, leading to their preferences and concerns not being included in their care plans. One resident, with moderate cognitive impairment, had no documented care conferences and expressed a desire to discuss her care. Another resident, cognitively intact, had not had a care conference since his last MDS assessment and had concerns about room placement. The Social Services Director acknowledged being behind on scheduling due to staffing issues, and the DON and Administrator were unaware of the missed conferences.
A resident with severe cognitive impairment and heart failure experienced a significant weight loss of 10.2% over several months due to the facility's failure to adequately assess and monitor their nutritional status. Despite policy requirements, the facility did not consistently reweigh the resident or notify medical staff of significant weight changes. The RD recommended weekly weights and increased supplements, but these were not implemented, and the Unit Manager was unaware of the weight loss. The DON confirmed no frequent weight monitoring was initiated, and there was no documentation of notifying the medical doctor.
A resident with dementia was found with topical medications, Dakin's Solution and Remedy Barrier Creme, left unattended in their room, leading to an alleged ingestion incident. The medications were intended for the resident's roommate, and staff interviews revealed uncertainty about how they ended up in the room. The resident was sent to the emergency room for evaluation, where no ill effects were found.
The facility failed to protect residents from abuse, as evidenced by two incidents where a CNA verbally abused a resident and another CNA was rough during incontinence care, causing a skin tear. Both residents were cognitively intact and reported the incidents, leading to the termination or removal of the involved CNAs.
A facility failed to timely report an allegation of physical abuse involving a resident who sustained a skin tear during incontinence care. The incident was reported to the state survey agency several days late due to the RN's belief that it was more related to resident behavior than abuse. The Administrator acknowledged the delay and confirmed the incident should have been reported immediately.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
F600 was cited for failure to ensure a cognitively impaired female resident remained free from sexual abuse when another resident initiated inappropriate sexual contact. The incident involved a female resident with vascular dementia, Parkinson’s disease, and bipolar disorder, whose quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment and need for assistance with ADLs. The other resident involved had bipolar disorder, was cognitively intact with a BIMS score of 13, and had a documented history of inappropriate behavior and inappropriate gestures toward staff. According to the report, a nurse observed the male resident seated close to the female resident in the dayroom/dining area with a blanket over his lap. When the blanket was removed, his genitals were exposed and he was holding the female resident’s wrist/hand in his lap. The nurse reported that the male resident had his hand around the female resident’s wrist and was using her hand to masturbate. The female resident did not appear confused or frightened at the time of the observation, and later denied that she had done what was described. The record also showed the female resident had difficulty with decision-making at times and required redirection and daily structured programs. A psychiatric note described impaired judgment and concrete thinking, and the male resident’s record documented prior inappropriate behaviors. During interviews, the nurse, DON, and Administrator described the event as a sexual encounter/inappropriate touching between the two residents, with the male resident’s genitals exposed and the female resident’s hand in contact with them. The report states the facility failed to prevent the sexual contact from occurring between the cognitively impaired resident and the other resident.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report a successful, unwitnessed elopement involving a resident to the State Survey Agency as required. On 01/15/26 at approximately 2:30 PM, the resident left the facility through the staff exit after obtaining the door code from a former CNA and manipulating the keypad to open the door. The resident stated he wanted to leave, got past the dumpsters on the side of the building, and was almost to the street before being found by staff. The resident involved, R13, had diagnoses including heart disease, heart failure, Type 2 diabetes, dizziness and giddiness, right below-the-knee amputation, anxiety disorder, major depressive disorder, and PTSD. The resident reported that he exited through the employee-used door and was found by the Unit Manager, Housekeeper/Activities person, and Social Worker. The resident also stated he intended to go next door to get a Greyhound ticket and wanted out of the facility. Facility documentation reviewed showed no nursing notes regarding the elopement and no notes showing notification of the medical provider or responsible person. During interviews, the MSW stated she would have expected documentation because multiple staff were present, and said she notified the Administrator after the incident. The DON stated the incident was not reported, and the Administrator stated it was not reported because he did not think it rose to the level of elopement since the resident was in line of sight by an employee.
Failure to Supervise Resident During Elopement
Penalty
Summary
The facility failed to ensure Resident 13 was adequately supervised to prevent elopement, and the resident successfully left the facility unwitnessed on 01/15/26. The resident was later found by staff on a gravel road leading toward the main street, approximately 200 feet from the door he exited. The report states that no clinical notes were written and no clinical assessments were completed after the elopement, and there were also no notes showing that the resident’s medical provider or responsible person was notified. Resident 13’s record showed diagnoses including heart disease, heart failure, Type 2 diabetes, dizziness and giddiness, right below-the-knee amputation, anxiety disorder, major depressive disorder, and PTSD. His quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive deficits, and he used a manual wheelchair independently while needing partial assistance for personal care. His care plan identified him as at risk for elopement and wandering, with interventions including identifying him to staff as an elopement risk, ensuring his physical needs were met, and assessing him for activities of interest. The resident’s elopement risk observation documented a history of attempting to leave the facility, expressed discontent with the facility, and a diagnosis requiring supervision. During interview, the resident stated he rolled out through the employee exit, obtained the code from a CNA who used to work there, and wanted to leave the facility. Staff interviews described that he exited through a staff door on the 100 Hall near the meeting room, went past the dumpsters, and was found near the dirt road heading toward Battleship Road. The MSW, DON, Administrator, Unit Manager, and dietary staff gave differing accounts of how far he had gone and who saw him, but all confirmed he had left the building area and was located outside the facility.
Care plan not updated for DNR status
Penalty
Summary
The facility failed to update and revise R25’s care plan to reflect the resident’s election for DNR status. R25 was admitted with diagnoses including aphasia, hypokalemia, hypomagnesemia, a lump in the right breast, disorders of bone density and structure, and vascular dementia. The record showed an order for hospice and palliative care with an admitting diagnosis of vascular dementia, and physician orders included CODE STATUS: DNR. A telephone order also documented DNR, and the South Carolina POST form later showed a selection for Do Not Attempt Resuscitation/DNR (Allow Natural Death) after an earlier POST had selected Attempt Resuscitation/CPR. Despite these documents, R25’s care plan still listed the problem as “Advance Care Planning: Code Status is Full Code” and stated that copies of advanced directives included “Full Code.” The care plan also directed staff to ensure the resident’s care wishes were aligned with written advanced directives or documented requests, but it was not revised to match the DNR status. During interviews, the LPN MDS Coordinator stated that social services usually changes code status when it is changed, and the Social Services Assistant and Social Services Director stated they were responsible for updating code status. The SSD said the family switched R25 to DNR and acknowledged the care plan could have been a mistake, stating she would update it right away. The Administrator stated the expectation was to update them as changes are made.
Inaccurate Narcotic Count Documentation
Penalty
Summary
The facility failed to maintain accurate narcotic medication records for 2 of 6 medication carts reviewed for medication storage. Facility policy required controlled substances to be accounted for on a Controlled Substance Record and for medication administration to be documented immediately after the medication was given, with initials on the MAR and verification of counts at change of shift. During review of the 100 Hall medication cart, seven instances were found in which the count of residents' narcotic medications did not match the narcotic count sheets. During review of the 200 Hall medication cart, two instances were found in which the count of residents' narcotic medications did not match the narcotic count sheets. During interviews, an LPN stated she documented on the narcotic count sheets after completing the medication pass because she did not want medications to be late and said she forgot to document that day. Another LPN stated she was distracted while giving medications and normally signs the narcotic sheets as soon as she gives the medications. Unit Managers stated narcotics should be signed out as soon as they are given to the resident. The DON stated the expectation was that nurses document narcotics as soon as they are given and verify counts at change of shift, and she acknowledged that one nurse had already received verbal counseling and a final warning for not documenting seven instances of narcotic administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5 percent, with a documented error rate of 10.34 percent based on 3 errors out of 29 opportunities. Review of the facility’s medication administration policies showed that insulin pens were to be primed before use and that liquid medications such as Miralax were to be measured and diluted according to specified amounts. During observation, an LPN administered 5 units of Aspart insulin (Novolog) to a resident with diabetes mellitus without priming the insulin pen, and the LPN confirmed this omission during interview. The same LPN also administered Miralax 17 grams mixed in 3 ounces of water instead of the required 6 to 8 ounces, and confirmed the incorrect dilution. In a separate observation, the same LPN administered 24 units of Lantus insulin to another resident with diabetes mellitus and again failed to prime the insulin pen, which she also confirmed.
Insulin Pen Not Primed During Administration
Penalty
Summary
The facility failed to ensure two residents were free from significant medication errors related to insulin administration via Kwik Pen. The facility policy for insulin pen administration required the pen to be primed before use, including dialing 2 units and expelling insulin until a drop or stream appeared at the needle tip. Review of the residents’ records showed both had diagnoses of diabetes mellitus. During observation, an LPN administered 5 units of Aspart insulin (Novolog) to one resident without priming the insulin pen, and then confirmed in interview that the pen had not been primed before administration. Later, during observation and interview, the same LPN administered 24 units of Lantus insulin to a second resident and again failed to prime the insulin pen. The LPN confirmed the failure to prime the pen for the second resident as well and could not confirm that either resident received the correct insulin dosage because the pens had not been primed.
Pest Control Program Failed to Prevent Infestation
Penalty
Summary
The facility failed to ensure it was free of pests in 3 resident rooms on 2 different units. The facility policy titled Pest Control stated the facility would maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. A service report from Ecolab dated 01/22/26 documented that selected areas were inspected and treated, with pest activity found. The report noted bed bugs during treatment in room 311 and stated that patient/guest rooms were inspected and serviced. The report also documented that rooms 113 and 331 were serviced and could be returned to service after sitting one hour and a thorough deep clean. During observation and interview, a roach was seen crawling in the sanitizer station near a resident's bathroom in one room, and the resident stated there were always bugs in the room, including in the lights, sanitizer container, and on the ceilings. In another room, the resident's belongings were observed packed in trash bags on the bed and later placed in the hallway on a rack while the room was being deep cleaned. Staff interviews indicated the room was sprayed after the resident reported seeing a roach, but the Maintenance Director stated he had not seen any roaches after the spray treatment. Additional resident interviews described seeing roaches, little black bugs, and bugs coming from the ceiling, and during a survey team meeting a roach was observed crawling across the meeting room table.
Failure to Administer Seizure Medications as Ordered
Penalty
Summary
A significant medication error occurred when a resident was admitted to the facility with physician's orders for multiple seizure medications, including Keppra, Vimpat (Lacosamide), and Zonisade. The facility failed to administer these medications as ordered, resulting in the resident missing one dose of Keppra, three doses of Vimpat, and two doses of Zonisade. The resident had a medical history of metabolic encephalopathy, seizure disorder, and status epilepticus, and was admitted following a hospital discharge. The failure to provide the prescribed seizure medications was due to several factors. The medications Vimpat and Zonisade were not delivered by the pharmacy, and there was no hard script sent from the hospital for Vimpat. The Keppra was delivered late in the evening, after the scheduled administration time. Nursing staff did not promptly notify the provider about the unavailability of the medications, and the required medication reconciliation and provider communication were not completed in a timely manner. The DON and LPNs involved confirmed that the missed doses were not identified or communicated to the provider until after the resident had already missed several doses. As a result of the missed doses, the resident experienced seizure activity and was found unresponsive with seizure-like activity by staff after a family member alerted them. The resident had a total of six seizures, each lasting one to three minutes, and was subsequently transported to the hospital. Interviews with facility staff and the nurse practitioner revealed that there was a lack of timely communication regarding the missing medications and the need for provider intervention, which contributed to the resident's adverse event.
Deficient Kitchen Sanitation and Cleaning Practices
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, specifically concerning the kitchen floor and the deep fryer. Observations on two separate occasions revealed that the kitchen floor was sticky and dirty, with food crumbs and grease splatters present. The deep fryer was found to be heavily soiled with caked dried grease on various parts, including the top, sides, and wheels. Interviews with the Dietary Assistant and Dietary Manager confirmed the lack of cleanliness, with the Dietary Manager acknowledging the need for cleaning and the Dietary Assistant noting that the fryer had been in this condition for some time. The facility's cleaning schedule, as per their Nutrition Policies and Procedures, required daily sweeping and mopping of the kitchen floor and weekly cleaning of the deep fryer. However, documentation showed that these tasks were not consistently completed, with the floor cleaning only documented once in a week and the deep fryer cleaning not documented at all for the specified period. The Dietary Manager, who had been in the position for three weeks, stated that the floors were supposed to be cleaned every night, but the lack of documentation and the observed conditions indicated otherwise. The Administrator also confirmed the unsatisfactory state of cleanliness during an inspection.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications according to physician's orders for six residents. The facility's policy allows medications to be administered within one hour before or after the designated time. However, observations and interviews revealed that a registered nurse was behind on medication administration, resulting in late administration for several residents. The nurse's computer screen showed nine resident profiles in red, indicating late medications, and the nurse admitted to being behind all day. A licensed practical nurse and unit manager confirmed the delays and assisted the registered nurse in catching up with the electronic medication administration system. The electronic Medication Administration Records (MAR) showed that medications for six residents were administered late. For example, one resident received Gabapentin, Carvedilol, and Acetaminophen hours after the scheduled time. Another resident received Hiprex, Metoprolol tartrate, and a nutritional supplement late. Other residents also experienced delays in receiving medications such as Hydralazine, Tizanidine, Alprazolam, Creon, and Sodium bicarbonate. The Director of Nursing stated that staff should notify the physician and family if medications are late and monitor the resident's response after administration.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. Staff did not consistently use the required personal protective equipment (PPE) or perform hand hygiene when caring for residents under Enhanced Barrier Precautions (EBP). For instance, a Certified Nurse Aide (CNA) provided personal hygiene care to a resident with a Foley catheter without wearing a gown, despite signage indicating the need for gowns and gloves. Similarly, a Unit Manager did not perform hand hygiene before applying gloves while providing wound care to another resident, and a CNA assisting in the same room did not initially wear the required PPE. The facility also failed to sanitize patient care equipment between uses. A Registered Nurse (RN) did not sanitize a blood pressure machine after using it on one resident before it was used on another. This oversight was acknowledged by the RN, who realized the lack of sanitizing supplies on the medication cart. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed that equipment should be sanitized between uses, but this practice was not consistently followed. Additionally, housekeeping staff did not adhere to PPE and hand hygiene protocols while cleaning rooms under EBP. Observations revealed that housekeepers either did not wear gloves or failed to perform hand hygiene after handling soiled materials. Furthermore, the facility did not offer COVID-19 immunization education or track immunization status for some residents, as required by their policy. The Infection Prevention Nurse admitted to not having documentation of COVID-19 immunizations being offered to certain residents, and the DON confirmed that all residents should be offered the vaccine and education, with documentation of consent or declination.
Failure to Notify Physician of Resident's Pressure Ulcers
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as R134, which delayed treatment for pressure ulcers. R134 was admitted with diagnoses including protein-calorie malnutrition and an unspecified open wound to the left lower leg. Upon admission, R134 was found to have two unstageable pressure ulcers on the sacrum, which were not included in the hospital discharge summary. The facility's policy required that any significant abnormal findings be reported to the physician, but this was not done in a timely manner. The Director of Nursing confirmed that the admitting LPN assessed R134 and noted excoriation to the sacrum, applying barrier cream but failing to notify the physician or obtain orders for wound care. Physician orders for the sacral wounds were not obtained until several days after admission. This oversight was contrary to the facility's wound care policy, which mandates immediate evaluation, reporting, and documentation of skin condition changes.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation of an altercation between two residents, R59 and R0, which was reviewed for abuse. R59, who had dementia and bipolar disease, was admitted to the facility and was known to wander in the living unit. R0, diagnosed with schizoaffective disorder and dementia with agitation, was involved in an incident where R0 slapped R59 after a verbal exchange in the dining room. The facility's investigation documented the incident as abuse and noted that staff could not prevent R0 from slapping R59. Despite the facility reporting the incident within the required two-hour timeframe and initiating an investigation, there was no evidence that residents who witnessed the altercation were interviewed to assess their sense of safety or any impact on their psycho-social wellbeing. The Social Services Director (SSD) admitted to not conducting any safety check interviews with other residents in the dining room following the incident. This lack of comprehensive investigation and follow-up with other residents present during the altercation contributed to the deficiency identified by the surveyors.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, R80 and R93, which placed them at risk for unmet care needs. For R80, who was admitted with dysphagia and dementia, the care plan was not updated to include necessary referrals and consultations following a fall that resulted in a laceration. Despite the Interdisciplinary Team's (IDT) decision to request a neurology consultation and a referral to a memory care unit due to R80's wandering behaviors, these actions were not documented or followed up on. The Director of Nursing and the Social Services Director both confirmed the lack of follow-up and documentation for these critical referrals. For R93, who required dialysis due to end-stage renal disease, the care plan included a directive not to take blood pressure on the arm with the dialysis fistula. However, during an observation, a Certified Nursing Assistant attempted to apply a blood pressure cuff to the arm with the fistula, indicating a failure to adhere to the care plan. The Unit Manager intervened to correct the action, but the incident highlighted a lapse in communication and adherence to the care plan directives, as evidenced by the posted sign in the resident's room that was not initially followed.
Failure to Conduct Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that care conferences were held for two residents, which increased the risk of their preferences and concerns not being included in their care plans. Resident 72, who was cognitively intact upon admission but later showed moderate cognitive impairment, had no documented care conferences since her admission. She expressed a desire to discuss her care, particularly regarding a gastroenterology consult, but had not been invited to any care conferences. Similarly, Resident 86, who was cognitively intact, had not had a care conference since his last MDS assessment, despite expressing concerns about his room placement. The Social Services Director (SSD) confirmed that care conferences were expected to be held quarterly in coordination with MDS assessments, but acknowledged being behind on scheduling them due to being the only social worker during a specific period. The Director of Nursing (DON) and Administrator were unaware of the missed care conferences for both residents and stated that it was the Social Services department's responsibility to send out invitations. The lack of care conferences for these residents was not documented in their medical records, indicating a failure in the facility's care planning process.
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and monitor the nutritional status of a resident, identified as R46, who was reviewed for weight loss. R46, who was severely cognitively impaired and diagnosed with heart failure, experienced a significant weight loss of 10.2% from July to January. Despite the facility's policy requiring reweighing and notification of significant weight changes, these actions were not consistently followed. The resident's care plan included interventions such as obtaining weights per protocol and notifying the medical doctor of significant weight changes, but these were not effectively implemented. The Registered Dietitian (RD) noted a weight loss of 5% in one month and 10% over three and six months, recommending weekly weights and increased supplement intake. However, weekly weights were not performed, and the RD was not provided with further weights to validate changes. Interviews revealed that the Unit Manager was unaware of the resident's weight loss and the need for weekly weights, and the Director of Nurses confirmed that no frequent weight monitoring was initiated by medical staff. Additionally, there was no documentation of staff notifying the medical doctor of the identified weight loss, and no in-services were conducted to re-educate staff on weight monitoring.
Unattended Medications Lead to Potential Ingestion Incident
Penalty
Summary
The facility failed to ensure that two topical medications, Dakin's Solution and Remedy Barrier Creme, were not left unattended in a dementia resident's room, leading to a potential ingestion incident. The medications, intended for the resident's roommate, were found in the room, and it was alleged that the resident had ingested the Dakin's Solution. The facility's policy requires medications to be stored securely and only accessible to authorized personnel, which was not adhered to in this case. Interviews with staff revealed uncertainty about how the medications ended up in the room and whether the Dakin's Solution was ingested, as the bottle was found empty. The resident involved, who has a history of metabolic encephalopathy and vascular dementia, was unable to participate in a mental status interview due to cognitive impairments. The incident was reported by the resident's roommate, who has a history of fabricating stories. Despite this, the resident was sent to the emergency room for evaluation, where tests showed no ill effects from the alleged ingestion. The facility's failure to secure medications as per policy resulted in a potential risk to the resident's safety.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by staff, as evidenced by two incidents involving residents. In the first incident, a resident with diabetes mellitus, neuropathy, and paraplegia, who was cognitively intact, reported that a CNA made offensive and inappropriate comments, cursed, and yelled at them after they requested their coffee to be heated. The incident was substantiated by an LPN who witnessed the altercation, leading to the termination of the CNA's employment. The resident and their roommate confirmed the loud argument, although the roommate could not recall specific details of the exchange. In the second incident, a resident with chronic pain syndrome, osteoarthritis, and anxiety disorder, who was also cognitively intact, reported that a CNA was rough during incontinence care, resulting in a skin tear on the resident's left arm. The resident admitted to swinging at the CNA, who then grabbed the resident's arm to prevent being hit. The facility's investigation found that the CNA did not willfully inflict injury, but the CNA was removed from the facility. The resident did not express ongoing distress from the incident, and the nurse who treated the skin tear confirmed the resident's account. Both incidents highlight the facility's failure to ensure a safe environment free from abuse, as required by their policy. The facility's leadership prohibits all forms of abuse and mandates immediate reporting and investigation of any allegations. Despite these policies, the incidents involving verbal and physical altercations between staff and residents indicate lapses in adherence to these standards, resulting in harm and distress to the residents involved.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse to the state survey agency for one resident. The facility's policy mandates that any abuse allegations must be reported immediately, but not later than 2 hours if serious bodily injury is involved, or within 24 hours if not. In this case, a resident reported that a CNA had been rough during care, resulting in a skin tear. The incident occurred on 02/02/24, but the state survey agency was not notified until 02/06/24, which was beyond the required reporting timeframe. The delay was due to the RN's belief that the incident was more related to resident behavior than abuse, and the Administrator confirmed that the incident should have been reported immediately. The resident involved was admitted with diagnoses including chronic pain syndrome, osteoarthritis, and anxiety disorder, and was cognitively intact with a BIMS score of 15. The resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. During the incident, the resident swung at the CNA, who then put up her arm to block the swing, resulting in a skin tear. The RN cleaned and treated the skin tear but did not report the incident as abuse until several days later. The Administrator acknowledged the reporting delay and confirmed that the incident should have been reported to the state agency on the day it occurred.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Camden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kershaw Health Karesh Long Term Care | 4.6 mi | ★★★★★ | 1 | 0 |
| Pruitthealth- Ridgeway | 8.9 mi | ★★★★★ | 10 | 0 |
| Ridgeway Manor Healthcare Center | 16.4 mi | ★★★★★ | 13 | 0 |
| Pruitthealth- Blythewood | 17.2 mi | ★★★★★ | 2 | 0 |
| Wildewood Downs | 18.4 mi | ★★★★★ | 2 | 0 |
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