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 deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.

Removal Plan

• The Administrator notified the Medical Director of the Immediate Jeopardy.
• R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
• R2 was sent to the emergency department for a higher level of care.
• The Assistant Director of Nursing began the investigation into the medication error.
• The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
• The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
• The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
• The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
• The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
• The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
• The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
• The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
• The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
• Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
• The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.

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 timely report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within two hours, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, last revised in September 2022, states that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the Administrator and appropriate authorities, defining "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury. Despite this, the medication error involving Resident 2, which led to hospitalization, was not entered on the facility’s reportable incident log and was not reported to the State Agency or Administrator as required. Resident 2 was admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. On the morning of 12/04/25, LPN1 pre-pulled medications for more than one resident at a time and prepared medications for Resident 2 and Resident 3. When Resident 3 requested pain medication, LPN1 retrieved oxycodone for Resident 3 but then became distracted and administered Resident 3’s medications to Resident 2 instead. Witness statements from the Unit Manager and ADON documented that Resident 2 received multiple medications not prescribed for them, including oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide, gabapentin 600 mg, and metoprolol 50 mg. Progress notes show that Resident 2’s blood pressure remained low despite ordered midodrine and fluids, with documented hypotension, bradycardia, and decreased respirations, and the resident was ultimately transferred to the hospital for further evaluation. Following the error, LPN1 reported the incident to her supervisor, and the ADON and NP were notified; however, the Administrator and State Agency were not notified as required by policy. The DON, who was on maternity leave at the time, later stated that the incident should have been reported to the State Agency but confirmed that no report was submitted and that the ADON was unaware the incident needed to be reported. The ADON stated she was unsure if the Administrator had been notified and acknowledged she did not know she was required to report the incident to the State Agency. The Facility Administrator reported that he only became aware of the medication error recently, after speaking with another resident, and confirmed that no report had been sent to the State Agency and that he had not been informed of the incident when it occurred.

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 an NPO (nothing by mouth) resident was adequately supervised and protected from receiving food and fluids by mouth. The resident had an active physician’s order for NPO status and a care plan identifying high nutrition risk related to dysphagia and dependence on enteral nutrition for 100% of nutrient and energy needs, along with functional quadriplegia, history of subarachnoid hemorrhage, and epilepsy. The resident’s MDS indicated memory problems and use of a feeding tube as the nutritional approach. Despite these documented needs and restrictions, the resident was able to obtain and consume a cereal bar and water provided by visitors from a church group. On the day of the incident, a CNA observed the resident in his room with a cereal bar in his mouth and removed it from his hand, then notified the nurse. Another LPN later observed a cereal bar in a blue wrapper and a Styrofoam cup, noting that the resident had some of the bar in his mouth and some in his hand, with about half of the bar already in his mouth and all of the water gone. The resident could not identify who had given him the items. Staff interviews and the medical director’s account indicated that the food and drink were given by an unknown church member or group visiting the facility, and that such missionary visits were common on weekends. Following ingestion of the cereal bar and water, the resident developed symptoms including vomiting, sweating, clamminess, and gurgling, as documented in an Interact SBAR completed by an LPN. The SBAR noted that the event started with these symptoms after the resident ate a cereal bar from a church member, and recorded a blood pressure of 184/108. The NP reported being called by the nurse and informed that the NPO resident had received a cereal bar and water earlier that day and was now experiencing projectile vomiting and clamminess, and she ordered the resident to be sent to the hospital. Hospital records show the resident was admitted for vomiting, with a history of intracerebral hemorrhage, stroke, and schizophrenia, and was intubated for airway protection with suspected aspiration pneumonia, later requiring a tracheostomy. The state agency determined that the facility’s non-compliance with accident hazard and supervision requirements constituted Immediate Jeopardy at F689, effective as of an earlier date.

Removal Plan

• Assess the identified resident following the incident and implement provider orders.
• Discharge the resident to the hospital.
• Assess residents with nothing-by-mouth orders for change in condition, including changes in vital signs, respiratory distress, and gastrointestinal distress.
• Place a sign at the entrance of the facility instructing visitors and delivery drivers to consult with a nurse prior to delivering or providing food or drink to a resident.
• Post signs in rooms of residents with nothing-by-mouth orders identifying the resident as nothing by mouth and instructing staff/visitors to contact the nurse prior to providing any food or drink.
• Reeducate facility staff on the policy for food brought in from outside sources, including instructing staff to question visitors providing food/drink and to request visitors notify the nurse prior to providing food/drink to a resident.
• Complete audits of food distributed from outside sources to validate proper distribution.
• Hold an ad hoc QAPI meeting.
• Notify the Medical Director and provide updates on interventions completed.

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 administer operations in a way that ensured effective and efficient use of resources, resulting in interruptions to food service, oxygen supply arrangements, linen availability, and an incomplete facility assessment. Surveyors reviewed the facility’s undated and unsigned Business Continuity policy, which stated that critical resources would be identified, contracts with two or more vendors would be maintained, and emergency supplies would be stored at established par levels. The policy also called for ongoing evaluation of communication, resources, utilities, staff, food and water, and safety and security when sheltering in place. A separate undated and unsigned Compliance and Ethics Program policy stated that the facility would assign high-level personnel to oversee compliance, ensure sufficient resources and authority to assure compliance, and review the program annually to promote quality care. During the kitchen tour, surveyors observed that more than 90% of products in the freezer, cold, and dry storage areas bore a food delivery date corresponding to the day of survey, while photos taken earlier that morning by the Dietary Manager showed those same storage areas empty or nearly empty, with between zero and four items. The Administrator and ADON acknowledged that the survey was likely related to food delivery issues and stated this was the second time food delivery had been cut off for nonpayment, with the facility’s U.S. Foods account suspended and two scheduled deliveries missed. The Dietary Manager reported that this was actually the third such occurrence, that food deliveries normally occurred twice weekly, and that the last delivery before the suspension had been on a date when the account was subsequently cut off, causing missed orders. Receipts showed that menu items had to be purchased from local vendors, and payment records from U.S. Foods documented repeated large lump-sum payments made after multiple past-due charges had accumulated, with the account being suspended for nonpayment on multiple occasions. In the laundry area, surveyors observed covered racks of clothing awaiting distribution and bins of personal clothing to be folded, but no linens awaiting distribution and no emergency linen supply. Dirty linens were present in bins awaiting laundering. Invoices from a linen and medical supply vendor showed multiple orders for towels, washcloths, and sheets with 30‑day payment terms over several months, with unclear payment status. The Medical Supplies Clerk stated that ordered items frequently did not arrive because invoices had not been paid, that she would be told by vendors that payment was needed before further orders could be filled, and that this occurred several times per year. She reported that when supplies could not be ordered, items were sometimes obtained from local stores or online, and that the facility had gone through several vendors because bills were not paid. Surveyors also reviewed communications with the oxygen supplier, which showed the facility’s account placed on hold for being over the credit limit on multiple dates, with attached accounting statements. The Medical Supplies Clerk indicated she was responsible for central supply, including linen inventory and ordering medical supplies, and that outstanding invoices were reported to the Accounts Payable person. The Regional Director of Operations stated that the facility did not have a governing board, that the owner was the 100% owner, and that the corporate entity was considered the governing body. He described the owner as difficult to reach and personally signing checks, and he acknowledged that staff should not have had to worry about feeding residents or having enough supplies, and that lack of necessary supplies could affect morale and patient care. The Administrator reported that corporate cards used to purchase food and supplies were sometimes maxed out, that she did not know how much would be placed on the cards, and that although the owner “pulled them out at the last minute,” she was not confident they could get through an emergency. Review of the facility assessment showed it was undated, unsigned, and had been reviewed with the QAA Committee on a prior date, but several sections were blank or incomplete and lacked supporting documentation. A Profit & Loss Budget Overview for a recent month showed a negative net income. When asked about corporate compliance documents, bylaws, or operating policies, the RDO stated there were no bylaws or operating policy, that continuity of business was based on disaster preparedness, and that policies came from an external compliance store. Despite the posted corporate sign in the foyer emphasizing stewardship and improving quality of life, interviews and document reviews demonstrated repeated interruptions in critical vendor services for food, linens, and oxygen due to nonpayment or credit issues, and an incomplete facility assessment, all reflecting failures in the administration of the facility’s resources and compliance structures as observed by surveyors.

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 establish and demonstrate an active governing body that is legally responsible for setting and implementing policies for managing and operating the facility, including appointing a properly licensed administrator and ensuring an effective compliance and ethics program. Surveyors found no evidence of a governing board; the Regional Director of Operations (RDO) stated that there was no governing board, no names to provide, and that the owner was the 100% owner with no operating policy, and that “Mainstay” was described as the governing body without further clarification. The facility’s Compliance and Ethics Program policy was undated and unsigned, and although it stated the facility was committed to compliance and had designed, implemented, and enforced a compliance and ethics program with sufficient resources and authority, there was no evidence that this program was actually implemented. The RDO reported that policies came from a “compliance store” and confirmed there were no bylaws or operating policy, and continuity of business was described as being based on disaster preparedness. Surveyors also identified failures in facility assessment and financial/operational management. The facility assessment was incomplete, unsigned, and contained several blank or incomplete sections with many areas lacking supporting documentation, despite being reviewed with the QAA Committee. A Profit & Loss Budget Overview for a recent month showed a negative net income. Review of a U.S. Foods Customer Account Application showed that payment terms required timely payment of all charges, and the report notes that vendors were not getting paid, resulting in disruption in delivery of food and supplies to residents. Attempts to contact the owner and the accounts payable clerk by telephone and electronic communication were unsuccessful. The RDO indicated that the owner’s sister-in-law handled accounts payable and described reliance on corporate credit cards and a regional maintenance person with access to funds for emergency needs, but no formal governing structure, bylaws, or operating policies were provided to surveyors.

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 conduct and document a complete facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The facility assessment on file was undated in the report, not signed, and lacked evidence of review and active involvement by all required participants, with no signature page or other documentation identifying who participated in its development. Surveyors’ review of the assessment showed several sections were blank or incomplete and many sections lacked supporting documentation. During an interview, the Administrator and Regional Director of Operations confirmed that this incomplete and unsigned assessment was the only facility assessment available for review, and this inaction in administering the facility had the potential to affect all residents living in the facility. No specific residents, medical histories, or clinical conditions were described in the report.

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

Surveyors found that the facility failed to maintain an adequate supply of clean, good‑condition linens in The Home building, affecting all 58 residents there. During multiple tours of the 100 and 200 hallways, both linen closets consistently contained fewer than 10 towels, washcloths, fitted sheets, flat sheets, and pillowcases. A randomly selected washcloth was thin and torn at the seam, and sheets in the closets were worn and thin. In the laundry building, there were no clean linens awaiting distribution and no emergency supply of linens; only bins of dirty linens awaiting laundering were observed. Invoices from the linen supplier showed multiple orders for towels, washcloths, and sheets over several months, but it was unclear if or when these invoices were paid, and another order had only recently been placed. Staff interviews confirmed ongoing linen shortages and poor linen condition. The Administrator acknowledged that the linen closets were low and agreed that torn washcloths should not be used or present in the closets, further stating there was no emergency linen supply and that corporate delays in paying bills resulted in vendors refusing to send orders. The Housekeeping Supervisor reported frequent shortages, difficulty obtaining orders because bills were not paid, and reliance on local suppliers for last‑minute needs, also confirming there was no emergency linen stock. CNAs reported that there were not enough linens, especially washcloths and towels in the mornings, that this had been an issue for up to two years, and that it slowed or delayed resident care, sometimes resulting in residents not receiving baths when desired. A resident reported having to wait several times to be bathed because CNAs did not have enough supplies.

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 completely and accurately document the suspected cause of a resident’s finger fracture, contrary to its policy requiring that each medical record contain an accurate representation of the resident’s actual experiences. The resident had severe cognitive impairment, with BIMS scores indicating inability to complete interviews and impaired decision-making, and relied on staff to anticipate needs. Facility policy required documentation to be accurate, relevant, complete, and detailed enough to depict the resident’s care and responses. In the days surrounding the fracture, multiple progress notes documented significant behavioral disturbances, including the resident fighting staff during care, yelling, climbing and standing on the bed, striking at staff, appearing to experience visual hallucinations, and being very unsteady and weak. On one day, nursing staff documented that the resident was combative and required redirection and one-to-one care, and that bruising and swelling of the right ring finger were noted, prompting orders for Ativan, Tylenol, and an x-ray. Subsequent notes documented that x-rays were obtained, that there were conflicting radiology reports regarding the presence and location of a fracture, and that the resident continued to use his hand and fingers without signs of pain while buddy taping was ordered and implemented for several weeks. During interviews, the ADON, RN, MS clerk/CNA, and former DON all recalled that the resident had been standing on the bed, flailing his arms and legs, hitting or punching the walls, and being combative while staff attempted to provide care and obtain a urine sample. They indicated that the MS clerk had witnessed the resident punching the wall and that this behavior was believed to be the likely cause of the finger fracture. However, none of the contemporaneous progress notes documented that the resident was hitting or punching the wall, nor did they record this as a suspected cause of the fracture. The lack of specific documentation of the wall-punching behavior and its relationship to the injury resulted in an incomplete and inaccurate medical record regarding the cause of the resident’s fracture.

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 cognitively intact resident from physical abuse/mistreatment by a CNA. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, dementia without behaviors, dysphasia following cerebral infarction, and muscle weakness, and was dependent on staff for most ADLs. Despite the facility’s written policy prohibiting verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of property, an incident occurred in which this resident was physically struck by a staff member during care. According to witness statements, the incident occurred while the CNA was providing in-room care and directing the resident to move his leg into the bed. When the resident refused, the CNA “popped” or hit the resident on the leg/thigh. Another CNA, positioned at a linen cart between nearby rooms, reported seeing the CNA hit the resident after he refused to move his leg, and described both the CNA and the resident “passing lick back and forth,” indicating reciprocal hitting. The reporting CNA immediately informed the nurse on duty of what they had observed. The resident later reported to facility staff that the CNA had “popped” him with her hand. The CNA acknowledged in her written and verbal statements that she tapped or popped the resident on the thigh while telling him to roll over, characterizing it as playful and occurring in the context of a joking relationship and the resident’s resistance to care and sexually inappropriate comments. The DON and Administrator confirmed that the CNA admitted to popping the resident on the thigh and that the facility substantiated the allegation of abuse based on the resident’s report, the witness account, and the CNA’s own admission.

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 follow its abuse, neglect, exploitation, or mistreatment policy requiring that all alleged violations concerning abuse be reported immediately and verbally to the Facility Abuse Coordinator, the Administrator, and the State Survey and Certification Agency. The policy also states that employees have the right to report allegations directly to the state agency. Despite this, allegations of sexual abuse involving three residents were not reported to the State Agency within the required 2-hour timeframe. The abuse allegations were discussed in a morning staff meeting on 02/06/2026, and some staff reported learning of the allegations as early as 02/04/2026 and 02/05/2026, but there was no timely notification to the State Agency as required. The residents involved all had significant cognitive impairments. One resident had diagnoses including cognitive communication deficit and dementia, with an admission BIMS score of 2/15 indicating severe cognitive deficits. Another resident had diagnoses including alcohol dependence with alcohol-induced persisting dementia, PTSD, anxiety disorder, major depressive disorder, and schizophrenia, and a Quarterly MDS documented that a BIMS was not conducted because the resident could not understand and was not understood. The third resident had diagnoses including dementia, TIA, cerebral infarction, convulsions, adult failure to thrive, and cocaine use, with a Quarterly MDS BIMS score of 6/15 indicating severe cognitive deficits. Allegations included one resident being observed by a CNA with her hands in the brief of another resident, and a separate allegation that two residents had sexual intercourse when one was found in the bed of the other. Progress notes for all three residents contained no documentation of alleged abuse, and although multiple staff members, including department heads and LPNs, were aware of the allegations and the allegations were reported to a nurse when they occurred, staff did not report them to the Abuse Coordinator, and the Abuse Coordinator did not report them to the State Agency.