Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 2
Mar 11, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards, including proper use of medical devices and infection prevention protocols, following a recent admission of a resident with multiple traumatic injuries.
Findings
The facility failed to ensure an active order for a cervical thoracic orthosis (CTO) neck brace for Resident 17, despite the resident's need and hospital discharge instructions. Additionally, the facility failed to properly handle and transport resident laundry, risking contamination between clean and soiled linens.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure an active order for the use of a Cervical Thoracic Orthosis (CTO) neck brace for Resident 17. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper handling and transportation of resident laundry, resulting in clean linen being placed on top of dirty linen without proper cleaning or covering. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: 1
Date of hospital visit: Feb 24, 2025
Date of order review: Mar 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse and Interim Director of Nursing | Interviewed regarding CTO brace order and resident care |
| MD1 | Medical Director | Interviewed regarding CTO brace order and hospital discharge instructions |
| RN2 | Admissions Nurse | Interviewed regarding responsibility for entering hospital orders into EHR |
| ED | Executive Director | Interviewed regarding procedural failures related to CTO brace order and laundry handling |
| Director of Facilities | Interviewed regarding laundry handling procedures | |
| Laundry Attendant | Observed improperly handling and transporting laundry |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 22, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the elopement of Resident 2 (R2) from the facility on 04/20/2023, which posed immediate jeopardy to resident health and safety.
Findings
The facility failed to prevent the potential for accidents and hazards related to elopement for one resident, R2, who exited the facility through an unalarmed door. The facility lacked adequate supervision and alarm systems to prevent or detect the elopement, placing the resident at risk of serious injury or death. Corrective actions included installation of door alarms, issuing a wander guard to R2, staff in-service training, and audits to monitor compliance.
Complaint Details
The complaint investigation found that Resident 2 eloped from the facility on 04/20/2023 at approximately 4:38 PM. The facility's failure to prevent this elopement constituted immediate jeopardy (IJ) to resident health and safety. The investigation included interviews, record reviews, and observation, confirming the lack of alarms on exit doors and inadequate supervision. The facility implemented corrective actions including door alarms, wander guards, staff training, and audits.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the nursing home area was free from accident hazards and to provide adequate supervision to prevent accidents, resulting in elopement of Resident 2. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Elopement Risk Assessment Score: 0
BIMS Score: 8
Residents identified at possible risk: 10
Audit duration: 28
Time resident was outside: 4
Temperature: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Worker 1 | Maintenance Worker | Witnessed Resident 2 walking outside and assisted in returning him to the facility |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Notified that Resident 2 was observed in the parking lot |
| Certified Nursing Aid 1 | Certified Nursing Aid | Was watching another resident during incident and interviewed about Resident 2's behavior |
| Certified Nursing Aid 2 | Certified Nursing Aid | Resident 2's CNA on day of elopement, last to see resident before elopement |
| Nursing Manager | Nursing Manager | Interviewed regarding lack of alarms and supervision on exit doors |
| Administrator | Administrator | Interviewed regarding facility knowledge of elopement and door alarm status |
Inspection Report
Annual Inspection
Deficiencies: 3
Aug 20, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication labeling and storage, nutritional needs and menu adherence, food preparation and sanitation, and overall facility operations.
Findings
The facility was found deficient in several areas including failure to date insulin pens when placed on medication carts, failure to follow the menu and serving sizes for meals, improper food preparation and storage practices, and inadequate sanitation and training of dietary staff. Multiple observations and interviews confirmed these deficiencies with minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to date insulin injection pens when removed from the refrigerator and placed on the medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow the menu for items served and serving sizes for one meal observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prepare and serve food and store kitchen dishware and pans in a sanitary manner and failure to discard leftovers within the scheduled timeframe. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Insulin injection pens not dated: 5
Observation date: Aug 17, 2021
Number of steam table pans observed: 38
Leftover storage timeframe: 7
Leftover storage timeframe: 3
Scoop size: 2.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated insulins should be dated when placed on medication cart. |
| Executive Chef | Executive Chef | Responsible for ensuring leftovers were discarded by shelf-life date and confirmed improper storage practices. |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding menu adherence, serving sizes, and dietary staff practices. |
| Registered Dietician | Registered Dietician | Confirmed staff should follow menu and serving sizes and provided training to kitchen staff. |
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