Citations in South Carolina n

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from verbal abuse when an LPN used curse words directed at the resident during a medication pass. Facility policy defined abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and specifically included verbal abuse as the use of disparaging or derogatory language toward residents. The resident involved had diagnoses including anxiety, major depressive disorder, schizophrenia, and tremors, and had a BIMS score of 15/15, indicating intact cognition. According to the facility’s investigation, the incident occurred when the nurse brought medications to the resident, who was not ready to take them and requested that the medications be left in the room. The nurse refused to leave the medications, attempted to retrieve the medication cup, and held the resident’s arm while trying to take the cup back. A CNA who was in the adjoining restroom reported hearing an argument between the nurse and the resident and stated that the nurse was holding the resident’s arm while trying to get the medication cup from the resident’s hand. The CNA reported hearing the word “c***” used a few times, and asked the nurse to leave the resident alone so the resident could calm down. In a separate interview, the resident stated that the nurse began yelling when the resident asked what medications were being given and repeatedly called the resident a “big fat c***” while trying to take the medication cup away. The resident reported feeling scared, particularly when the nurse returned the next day, and expressed not wanting the nurse to care for her again. The Administrator and DON later confirmed that the nurse had used inappropriate language toward the resident, with the DON stating that the nurse admitted to calling the resident a “b****.”

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe following an altercation between a resident and an LPN. Facility policy on Abuse, Neglect, and Exploitation requires that all suspected abuse, neglect, or exploitation be reported immediately to the Administrator, state agency, adult protective services, and other required agencies within specified time frames. The resident involved had diagnoses including anxiety, major depressive disorder, schizophrenia, and tremors, and a recent MDS showed a BIMS score of 15/15, indicating intact cognition. The incident occurred when the nurse brought medication to the resident, who was not ready to take it and requested that the medication be left in the room. The nurse refused to leave the medication and attempted to retrieve the medication cup, holding the resident’s arm while trying to take the cup from the resident’s other hand. A CNA, who was in an adjoining restroom, overheard the altercation and reported hearing “bad words” directed at the resident. The CNA intervened by asking the nurse to leave the resident alone so the resident could calm down and then reported the altercation to the Unit Manager at that time. Despite this report, the charge nurse did not notify facility leadership the night the incident occurred, and the nurse was not immediately removed from duty. The Administrator later stated that the charge nurse did not inform them when it happened, and the DON confirmed that the nurse admitted to calling the resident a derogatory name. The resident reported the incident after returning from the hospital, rather than at the time it occurred, and the required external reporting within 2 hours of the allegation did not occur as mandated by facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with a known history of frequent falls and severe cognitive impairment. The resident was admitted with diagnoses including a displaced left humerus fracture, severe dementia with anxiety, and muscle weakness, and was assessed as a high fall risk with a Morse Fall Scale score of 50. MDS assessments documented severe cognitive impairment (BIMS 00/15 and later unable to complete), daily wandering, delusional behaviors, inattention, disorganized thinking, and both short- and long-term memory loss. The resident was described as active, ambulatory, and impulsive, with a pattern of attempting to stand or ambulate without assistance and requiring consistent redirection. Between late August and mid-December, the resident experienced ten documented falls, three of which resulted in major injuries, including a nasal fracture, a subdural hemorrhage with a right clavicle fracture, and later a right femur fracture. Progress notes described multiple unwitnessed and witnessed falls in various locations, including another resident’s room, during ambulation to the shower room, behind the nurse’s station, in front of the wheelchair in the dining room, at the nurse’s station, and in the hallway. Despite this pattern of falls and injuries, the fall care plan interventions remained limited to measures such as ensuring proper pants length, using nonskid strips, offering redirecting activities, removing slippers from the room, placing a resident identifier outside the room, and assisting or redirecting the resident when seen walking without assistance. On the date of the cited incident, staff left a large grey rolling trash receptacle in the hallway near the exit door by the resident’s room, contrary to staff training that the trash can must be kept in the shower room and not left in hallways except when being emptied into the dumpster. The resident, known to be impulsive and ambulatory, exited the room, attempted to use the rolling trash can for support, and fell when it rolled away, striking the rail and holding the right upper thigh, with a subsequent diagnosis of a right femur fracture. The room’s location near an outside exit door and far from the nurse’s station, combined with the resident’s established fall history and behaviors, and the presence of the rolling trash can in the hallway, constituted the facility’s failure to identify and remove an environmental hazard for a high-risk resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBPs) and dressing change procedures, during wound care for one resident. The facility’s EBP policy requires gown and glove use for high-contact resident care activities, including dressing and wound care for residents with wounds, even when they are not known to be infected or colonized with MDROs. The dressing policy also outlines specific steps for hand hygiene, glove use, removal and disposal of soiled dressings, maintaining a clean field, and cleaning the bedside stand. These policies are intended to prevent the spread of MDROs and ensure clean technique during dressing changes. Resident 2 was admitted with multiple diagnoses including generalized muscle weakness, dysphagia (oral phase), and lumbar spine fusion, and had a care plan for a Stage II sacral pressure injury with interventions including skin care per facility guidelines and monitoring of the ulcer. During an observed sacral dressing change, an LPN entered the resident’s room and performed the dressing change without donning a gown, despite the EBP policy requiring gown and glove use for wound care. The LPN performed hand hygiene and glove changes but used a black marker taken from her pocket to label the dressing and did not clean the bedside table or the marker after use, contrary to the dressing policy’s requirement to clean the bedside stand. In a subsequent interview, the LPN acknowledged forgetting to wear PPE and confirmed that staff receive training on PPE requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse in the form of resident‑to‑resident altercations. Facility records and staff interviews show that one resident with dementia and mood disorder (R66) was involved in three separate physical conflicts on the secured unit. In one incident, a CNA entered a room and observed R66 scratching another severely cognitively impaired resident (R84) on the arm, resulting in a skin tear. In a second incident, an LPN at the nurses’ station saw R66 and another moderately cognitively impaired resident (R136) trying to pass through a doorway at the same time; R66 began flailing her arms and hit the other resident with open hands, after which the other resident struck R66 in the face with her fists. In a third incident, a CNA entered a room and saw R66 and another severely cognitively impaired resident (R120) grabbing each other; R66 had scratches on her face and blood on her mouth, and the other resident had scratches on her chest. Additional incidents involved other residents engaging in physical aggression toward one another. On one occasion, a resident with bipolar disorder (R93) approached a severely cognitively impaired resident (R125) who was seated in the dining room and struck her on the back multiple times with a closed hand. Staff witness statements documented that the striking was forceful and occurred multiple times, and progress notes recorded that the aggressor admitted to hitting the other resident and stated she understood after being told that hitting others was not acceptable. The facility’s internal investigation of this event was initially documented as unsubstantiated, despite staff accounts that the hitting occurred and that police were contacted for an incident number. The Administrator later acknowledged that this incident should have been substantiated as abuse because it happened. Another incident involved a severely cognitively impaired wandering resident (R115) and the same moderately cognitively impaired resident (R136) on the secured Memory Support Unit. Facility investigation notes indicated that R115 repeatedly wandered into R136’s room, prompting R136 to yell for her to get out. Staff redirected the wandering resident several times, and after the last entry into the room, staff seated R115 in the dining room. R136 then came from behind and slapped R115 in the face. The care plan for R136 already identified socially inappropriate and aggressive behaviors and directed staff to provide comfort measures when such behaviors began. The Administrator stated that residents on the Memory Support Unit “fight back there a lot” and that the facility usually substantiated such allegations because they occurred, noting that some residents did not like others in their personal space. Across these events, surveyors determined that the facility failed to ensure residents were free from physical abuse by other residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a safe environment and implement fall-prevention interventions as care planned for a resident with significant physical and cognitive impairments. The resident had diagnoses including right above-knee amputation, right hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, difficulty walking, and right-hand contracture. The resident sustained an unwitnessed fall from bed with head involvement, resulting in a hematoma to the right forehead and right eye, and was sent to the emergency room for evaluation. Subsequent assessments, including a Morse Fall Scale, identified the resident as high risk for falls, and the care plan was updated to direct staff to keep the bed in the lowest position due to the prior fall and the resident’s right AKA. Despite this care plan directive, multiple observations over two days showed the resident lying in bed with the bed elevated rather than in the lowest position. A CNA entered and exited the resident’s room without lowering the bed, and follow-up observations later that day and the next morning confirmed the bed remained elevated. During interviews, an RN acknowledged that the bed was not in the lowest position despite the resident’s fall risk and stated it should be as low as the mechanical bed would allow. The CNA reported that she only learned that day that the resident was a fall risk and that fall interventions were outlined in the care plan, including keeping the bed in the lowest position. Another LPN confirmed that the resident was at risk for falls and that the bed should be in the lowest position, and also stated that staff do not document bed position each shift.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that residents seated at the same dining table were served and assisted with their meals at the same time, affecting two residents reviewed for dignity in dining. One resident, identified as having short- and long-term memory problems and coded as dependent with eating on a significant change MDS, was observed seated in a reclined geri-chair at a dining table with her uneaten lunch tray in front of her while a CNA fed her tablemate. From 12:52 PM to 1:15 PM, the CNA continued feeding the tablemate while the dependent resident received no assistance with her meal. Only after the tablemate finished eating and was assisted out of the dining room did the CNA begin feeding the dependent resident at 1:17 PM, completing the feeding at 1:34 PM. The CNA confirmed that the dependent resident was served and assisted with her meal only after her tablemate had finished and left the dining room. A second resident, also documented on a quarterly MDS as having short- and long-term memory problems, was similarly affected on another day. This resident was seated in a reclined geri-chair next to the dining table without having been served a lunch meal, while staff fed the resident’s tablemate. From 12:35 PM to 12:45 PM, staff continued feeding the tablemate as the second resident remained without a meal and watched staff feed the tablemate. After staff finished feeding the tablemate and assisted her from the dining room at 12:47 PM, the second resident did not receive her lunch tray until 1:07 PM. The 400-hall unit manager (an LPN) confirmed that this resident was served later than her tablemate and explained that a second meal cart for the hallway arrived late due to a mix-up in the kitchen that was not communicated to hall staff. The Dietary Manager and the DON both acknowledged that residents seated at the same table should be served at the same time to promote dignity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a resident with ordered oral nutritional supplements and correct portion sizes during meals. The resident, admitted in 2016, had diagnoses including dysphagia, speech and language deficits following cerebral infarction, and dementia, and was care planned for a mechanically altered diet with supplements as ordered. The resident’s MDS indicated severely impaired cognitive skills for daily decision-making, no significant weight loss, and receipt of a mechanically altered diet. Active orders included a regular diet with pureed texture and thin liquids, daily ice cream with dinner for weight stability, an eight-ounce high protein oral nutritional supplement with lunch, and an oral nutritional supplement twice daily with breakfast and dinner for weight stability. During observation of the lunch meal on 01/12/26, the resident was served a pureed meal with an oral nutritional supplement, but not the ordered eight-ounce high protein oral nutritional supplement. During the dinner meal the same day, the resident received a pureed diet with ice cream, but no oral nutritional supplement was present on the tray. On 01/13/26 at lunch, a staff member plating the meal used a green #12 (2.67 oz) scoop for pureed salmon and pureed collard greens and a 2-oz serving spoon for pureed chicken. The staff member stated she determined portions from the production sheet and confirmed she had used a 2-oz spoon for the chicken and #12 scoops for the salmon and collard greens. After reviewing the production sheet, she acknowledged that she should have served 4 oz of pureed chicken, 4 oz of pureed salmon, and 1/2 cup of pureed collard greens, and that the scoops used were not the correct portion sizes. The Dietary Director confirmed the #12 scoop was slightly over a 2-oz portion. In interviews, nursing, dietary, and administrative staff stated that dietary staff were responsible for placing supplements on trays, that kitchen staff were expected to follow the menu and portion sizes so residents received nutritionally sound meals, and that ordered oral nutritional supplements should be provided as ordered for residents’ nutrition and weight management. The facility’s Food and Nutrition Services policy required that each resident be provided a diet that meets daily nutritional and special dietary needs and that food and nutrition services staff inspect food trays to ensure the correct meal is provided to each resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nursing services were provided by a licensed nurse when the Director of Nursing (DON1) worked while her nursing license was under temporary suspension. A document from the South Carolina Department of Labor Licensing and Regulation dated June 18, 2025, stated that DON1’s license to practice nursing in the state was temporarily suspended effective immediately, until further order of the Board. Despite this suspension, DON1 continued to work at the facility on June 18, 2025, and June 23, 2025, performing DON duties and providing nursing leadership oversight without a valid nursing license. The facility’s own job description for the Director of Nursing, signed by DON1, specified that the DON must be a registered nurse in good standing with the State Board of Nursing and responsible for overall management of the nursing department, staffing levels, resident safety, and direct resident care as needed. During the period of suspension, DON1 provided direct care and clinical oversight for at least two residents. For one resident (R4), the electronic medical record for June 2025 documented that on June 23, 2025, the resident approached DON1 to assess a large erythematous and ulcerated rash under the right pectoral area. The note indicated that the nurse practitioner and physician were made aware and examined the area, and that DON1 contacted the wound provider and obtained orders for Mycolog II cream twice daily for 14 days, Diflucan 100 mg by mouth daily for 5 days, Keflex 500 mg by mouth twice daily for 10 days, and Interdry application several hours after the cream. The documentation further showed that at 2:33 PM that same day, DON1 entered medication orders for Diflucan and Cephalexin for erythrasma, and later documented extensive interaction with the resident regarding showering and timing of leg wraps, including multiple reminders and an explanation of her need to leave the facility for an appointment. For another resident (R5), the electronic medical record for June 2025 showed that DON1 completed a weekly summary note and signed an interdisciplinary team (IDT) conference assessment on June 18, 2025, the same date her license suspension became effective. These entries indicated that DON1 was performing clinical assessment and documentation functions for this resident while not legally authorized to practice as a nurse. Human Resources staff later stated that they were unaware of the suspension at the time and that DON1, a salaried exempt employee who did not clock in and out, continued to perform typical DON duties during this period. The survey agency determined that the facility’s noncompliance with nursing services requirements, specifically allowing an unlicensed individual to function as the DON and provide direct resident care, constituted Immediate Jeopardy related to 42 CFR §483.35(c)(3) Nursing Services.

Removal Plan

• Notify the Medical Director of the Immediate Jeopardy and complete any additional required external notifications if applicable.
• Initiate a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; print/electronically save verification evidence and place it in personnel files.
• Complete a look-back investigation for all shifts worked by the ex-employee; assess/interview identified residents.
• Provide mandatory re-education to licensed nursing staff on the requirement to immediately notify the Administrator and/or DON of any license investigation, consent order, suspension, restriction, expiration, or other status change.
• Monitor compliance through QAPI; report results monthly for three months and quarterly for three additional quarters; QAPI Committee to re-evaluate need for further monitoring; Human Resource Director responsible for monitoring and follow-up.
• Upload current active nursing licenses for all licensed nursing staff into the facility’s human resources system to centralize and improve access to credential verification.
• Re-educate the Human Resources Director on the licensure certification and registration of personnel policy.
• Implement a process requiring all newly hired employees to sign an attestation that they must inform the Administrator/DON/HR Director of any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
• Initiate an attestation for all currently employed licensed personnel regarding responsibility to report any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
• Complete all attestations for licensed personnel; employees will not work until the attestation is completed.
• Implement a standardized license verification form and a central licensure tracking log with verification and expiration dates.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to have systems in place to verify licensure for nursing leadership, specifically the Director of Nursing (DON). The South Carolina Department of Labor, Licensing and Regulation issued an order dated June 18, 2025, temporarily suspending the DON’s nursing license effective immediately. Despite this suspension, the DON continued in her role, which, per her signed job description dated May 15, 2024, included overseeing and supervising the care of all residents, providing direct resident care as needed, managing the entire nursing department and staffing levels, ensuring resident safety, and supervising the ADON and all nursing staff. The job description also required that the DON be in good standing with the State Board of Nursing and maintain all required licensure requirements at all times. Human resources staff reported in interview that the DON was terminated on June 25, 2025, for conduct and unprofessionalism related to sexual harassment, and that they were unaware of the license suspension at the time of termination. HR stated that the DON was a salaried exempt employee who did not clock in and out, and HR could not specify what duties the DON performed while her license was suspended. Another DON, who assumed the DON role on June 25, 2025, stated that the previous DON would have performed typical DON duties and did not believe she was signed off for any patient care during the suspension period, but also indicated that they did not learn of the suspension until June 30, 2025, after conducting an internal audit prompted by information the former DON shared following her termination. During interviews, HR staff acknowledged that the facility did not have a policy for auditing licenses and that, for nurses, licenses were not checked between the two‑year renewal periods unless there was a specific reason to do so. The facility stated that licensure verification was performed at hire, at licensure renewal dates, and annually, but no verification occurred in the seven days between the Board’s temporary suspension order and the DON’s termination. The State Agency determined on February 14, 2026, that the facility’s non‑compliance with federal regulations related to administration could cause psychosocial harm, and Immediate Jeopardy was cited under 42 CFR §483.70, with the IJ determined to have existed as of June 18, 2025, due to the DON continuing to provide clinical oversight, supervise nursing staff, and provide direct resident care while unlicensed.

Removal Plan

• The Director of Nursing notified the Medical Director of the Immediate Jeopardy and will complete any additional required external notifications if applicable.
• The Human Resource Director initiated a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; no issues were identified.
• Verification evidence for all licensed nursing staff was printed or electronically saved and will be placed into appropriate personnel files.
• The Director of Nursing completed a look-back investigation for all shifts worked by the former Director of Nursing; the review found no evidence of resident harm or complaints, and residents were interviewed/assessed with no complaints or negative effects identified.
• Licensed nursing staff received mandatory re-education to immediately notify the Administrator and/or Director of Nursing if their license is under investigation, a licensure-related consent order is entered, or the license becomes suspended, restricted, expires, or changes status for any reason.
• The Human Resource Director will audit nursing licenses monthly for 3 months and then quarterly for 3 quarters; results will be reported to the QAPI Committee monthly for 3 months and quarterly for 3 quarters, with the QAPI Committee re-evaluating the need for further monitoring after these periods; the Human Resource Director will be responsible for monitoring and follow up.
• The Human Resource Director uploaded current, active nursing licenses for all licensed nursing staff into the facility's human resources system to ensure centralized and accessible credential verification.
• The Human Resource Director was re-educated by the Regional President and Assistant Regional Director of Clinical Services on the licensure certification and registration of personnel policy.
• The facility implemented a process requiring all newly hired employees to sign an attestation that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
• The facility initiated an attestation for all currently employed licensed personnel that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
• All attestations for licensed personnel will be completed or the employee will not work until the attestation is completed.
• A standardized license verification form and central licensure tracking log with verification and expiration dates will be implemented.