Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning participation, abuse reporting, and accident prevention in the nursing home.
Findings
The facility was found deficient in obtaining informed consent from a cognitively intact resident for psychotropic medication, ensuring resident participation in care planning, timely reporting of a resident-to-resident physical abuse incident, and providing adequate supervision to prevent a resident fall resulting in a hip fracture.
Deficiencies (4)
Failed to ensure informed consent was obtained from a cognitively intact resident prior to the use of a psychotropic medication.
Failed to ensure residents were afforded the right to participate in their care planning process.
Failed to timely report an allegation of physical abuse between residents to the State Survey Agency within two hours.
Failed to ensure supervision while toileting for a resident, resulting in a fall and right hip fracture.
Report Facts
Residents sampled for unnecessary medications: 20
Residents reviewed for falls: 30
BIMS score: 15
BIMS score: 11
BIMS score: 5
Medication dosage: 0.5
Staples count: 20
Staples count: 11
Staples count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN2) | Interviewed regarding informed consent for psychotropic medication for Resident 42 | |
| Assistant Director of Nursing (ADON) | Interviewed regarding informed consent process for Resident 42 | |
| Patient and Family Services Coordinator (PFSC) | Interviewed regarding resident participation in care planning | |
| Director of Nursing (DON) | Interviewed regarding expectations for resident care conference participation and supervision of Resident 112 | |
| Registered Nurse (RN1) | Documented and reported resident-to-resident abuse incident | |
| Registered Nurse (RN3) | Reported resident-to-resident abuse incident to Administrator | |
| Administrator | Abuse coordinator who failed to report resident-to-resident abuse incident to State Survey Agency | |
| Licensed Practical Nurse (LPN2) | Completed nursing progress note on Resident 112 fall | |
| Registered Nurse (RN2) | Completed nursing progress note on Resident 112 post-fall status | |
| Director of Rehabilitation | Interviewed regarding Resident 112 fall risk and cognitive status | |
| Certified Nursing Assistant (CNA2) | Interviewed regarding supervision and fall of Resident 112 | |
| Licensed Practical Nurse (LPN1) | Interviewed regarding Resident 112 ability to use call light and need for supervision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint survey related to a significant medication error involving Resident 1 (R1), where R1 received another resident's medications, constituting substandard quality of care.
Complaint Details
The complaint investigation found that R1 was given another resident's 9AM medications by a nurse, including Lantus, Humalog, Cetirizine, Cymbalta, Depakote, Gabapentin, Losartan, and Metformin. R1 exhibited symptoms such as dizziness, elevated pulse, and was sent to the emergency room where pneumonia was diagnosed. The medication error was reported by the nurse involved and management was notified. The facility provided monitoring and reeducation of staff following the incident.
Findings
The facility failed to ensure R1 was free from significant medication errors, resulting in immediate jeopardy to resident health or safety. R1 was given another resident's medications including insulin and other drugs, leading to symptoms such as dizziness, elevated pulse, and eventual hospitalization with pneumonia. The facility implemented corrective actions and an acceptable Immediate Jeopardy Removal Plan was provided and validated.
Deficiencies (1)
Failed to ensure residents are free from significant medication errors, resulting in R1 receiving another resident's medications.
Report Facts
Residents reviewed for medication error: 3
Residents affected: 1
Insulin doses given in error: 20
Insulin doses given in error: 8
Blood sugar reading: 151
Blood pressure reading: 136
Blood pressure reading: 22
Pulse rate: 113
Date of Immediate Jeopardy: Apr 29, 2024
Date of IJ removal plan: Sep 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Nurse who administered wrong medication to R1 and reported the incident |
| LPN1 | Licensed Practical Nurse | Supervising nurse who was notified of medication error and involved in monitoring R1 |
| NP | Nurse Practitioner | Assessed R1 after medication error and coordinated care including ER transfer |
| ADON | Assistant Director of Nursing | Interviewed regarding the medication error and monitoring |
| DON | Director of Nursing | Provided training and oversight following medication error |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of a comprehensive person-centered care plan for residents at high risk for falls.
Findings
The facility failed to develop and implement a complete care plan addressing the risk for falls for a resident with a history of falls and fractures prior to admission. The resident's care plan did not include interventions for fall risk despite assessments indicating high risk, and staff interviews confirmed gaps in care plan completion and communication.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically for a resident at high risk for falls.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Assessment Reference Date (ARD): Oct 26, 2023
Care Area Assessment (CAA) Detail Report Date: Nov 1, 2023
Quarterly MDS Assessment Dates: Jan 11, 2024
Quarterly MDS Assessment Dates: Apr 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager #4 | Nurse Manager | Interviewed regarding baseline care plans and care plan completion for resident R3 |
| Nurse Manager #2 | Nurse Manager and Falls Coordinator | Interviewed regarding care plan completion and therapy department responsibilities |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for care plans addressing fall risk |
| Administrator | Administrator | Interviewed regarding expectations for interventions to minimize fall risk and care plan accuracy |
Inspection Report
Routine
Deficiencies: 8
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident assessments transmission, care planning, treatment and care, food palatability, and kitchen hygiene practices.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, late transmission of Minimum Data Set (MDS) assessments, incomplete care plans for residents with indwelling catheters and use of compression stockings, failure to revise care plans accurately, failure to apply Tubigrip stockings as ordered, allowing a resident to perform catheter care without documented competency assessment, serving food that was often cold, unpalatable, or improperly prepared, and kitchen staff not following proper hygiene practices including hair and beard covering and hand hygiene. Additionally, food items in a nutritional refrigerator were not properly labeled or dated.
Deficiencies (8)
Facility failed to assess 1 of 8 residents for self-administration of medications, leading to medications being left accessible at bedside without proper assessment or orders.
Facility failed to transmit encoded, accurate, and complete MDS data within required timeframes for 4 of 28 sampled residents.
Facility failed to develop comprehensive care plans related to indwelling urinary catheters and use of Tubigrip stockings for 2 of 28 sampled residents.
Facility failed to revise care plan to accurately reflect current status for 1 of 28 sampled residents and failed to ensure 1 resident was invited to her quarterly care conference.
Facility failed to apply Tubigrip stockings per physician orders for 1 of 28 sampled residents.
Facility failed to ensure 1 resident was competent to perform suprapubic catheter care independently and failed to document assessments or obtain physician orders for self-care.
Facility failed to serve food that was palatable and at a safe and appetizing temperature for 7 of 7 residents reviewed for food palatability.
Facility failed to ensure kitchen staff wore hair nets covering all hair, beard guards, and did not touch food with bare hands or perform hand hygiene after contact with non-food items; also failed to ensure food items in a nutritional refrigerator were labeled and dated.
Report Facts
Residents sampled: 28
Residents affected: 131
Temperature of cowboy chili mac: 108
Temperature of breaded chicken: 115
Temperature of French fries: 105.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication administration and self-administration assessment deficiency |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration expectations and care plan deficiencies |
| MDS Coordinator (MDSC1) | MDS Coordinator | Confirmed late transmission of MDS assessments and care plan deficiencies |
| Nurse Manager/MDS Coordinator (NM3/MDSC2) | Nurse Manager/MDS Coordinator | Signed and transmitted late MDS assessment |
| Certified Nurse Aide (CNA)2 | Certified Nurse Aide | Interviewed regarding resident care and food palatability |
| Registered Nurse (RN)1 | Registered Nurse | Observed and interviewed regarding resident catheter care |
| Director of Dietary (DM) | Director of Dietary | Interviewed regarding food complaints and kitchen hygiene |
| Admissions Coordinator (AC) | Admissions Coordinator | Interviewed regarding resident food complaints |
| Director of Patient & Family Services (DPFS) | Director of Patient & Family Services | Interviewed regarding resident food complaints |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the unauthorized use of physical restraints on a resident (R1) without a physician's order.
Complaint Details
The complaint investigation found that CNA1 restrained resident R1 in his wheelchair with a linen sheet without a physician's order to prevent him from falling. The facility was notified of Immediate Jeopardy on 2/16/23 with an effective date of 2/2/23. The Immediate Jeopardy was removed on 2/17/23 after the facility provided an acceptable removal plan including 100% staff training on restraints and audits confirming compliance. The resident had been discharged on 2/2/23. Interviews with staff and review of medical records confirmed no physician orders or documentation supporting restraint use.
Findings
The facility failed to protect one resident from unauthorized physical restraints, specifically a linen sheet tied around the resident's waist for about 30 minutes without a physician's order. Immediate Jeopardy was identified and later removed after the facility implemented a removal plan including staff training and audits confirming no further unauthorized restraints.
Deficiencies (1)
Unauthorized use of physical restraints on resident R1 without a physician's order.
Report Facts
Date of survey completion: Feb 17, 2023
Staff training completion date: Feb 16, 2023
Resident discharge date: Feb 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in unauthorized restraint use finding |
| RN1 | Registered Nurse | Worked during the incident; no statement obtained |
| NA2 | Nursing Assistant | Reported CNA1's restraint use and sent photo to DON |
| DON | Director of Nursing | Interviewed regarding restraint incident and confirmed no documentation of behaviors or medication given |
| Administrator | Notified of Immediate Jeopardy and interviewed about photo evidence | |
| Medical Director | Informed of alleged events and involved in QAPI meeting |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 14, 2022
Visit Reason
The document is an annual inspection report for Nhc Healthcare - Greenwood, conducted as part of regulatory oversight to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected are unknown.
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