Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 147
Deficiencies: 7
Apr 15, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, medication administration, therapy recommendations, staffing postings, food safety, garbage disposal, and infection control practices at Riverside Health and Rehab.
Findings
The facility failed to promote resident dignity related to meal service in Styrofoam containers and privacy during medication administration; failed to assess residents' ability to self-administer medications; failed to implement therapy recommendations for hand splints; failed to post current nurse staffing information daily; failed to maintain food safety and cleanliness in the kitchen; failed to properly dispose of garbage; and failed to properly handle soiled linen, risking cross contamination.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Potential for minimal harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to promote resident dignity for 128 of 147 residents due to meals served in Styrofoam containers and failure to protect privacy during medication administration for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess residents' ability to self-administer medications for two residents, risking medication errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement therapy recommendations for hand splints for three residents, risking increased contractures and pain. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post current nurse staffing information daily, potentially misleading residents and visitors. | Level of Harm - Potential for minimal harm |
| Failure to ensure food safety and cleanliness in the kitchen, including unlabeled food, dirty equipment, improper storage, and unclean garbage area. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to dispose of garbage properly, with overflowing garbage and refuse on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly handle soiled linen by carrying unbagged linen out of a resident's room, risking cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 128
Residents affected: 34
Residents affected: 3
Residents affected: 147
Medications in cup: 13
Medications in cup: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in medication administration privacy and self-administration findings |
| RN1 | Registered Nurse | Named in medication administration privacy and self-administration findings |
| DON | Director of Nursing | Named in multiple findings including privacy, medication self-administration, therapy communication, and staffing postings |
| Dietary Manager | Dietary Manager | Named in food safety and kitchen cleanliness findings |
| Dietary [NAME] | Dietary Staff | Named in food safety and kitchen cleanliness findings |
| Rehabilitation Director | Rehabilitation Director | Named in therapy communication and splint use findings |
| Regional Director of Rehabilitation | Regional Director of Rehabilitation | Named in therapy communication and splint use findings |
| LPN1 | Licensed Practical Nurse | Named in soiled linen handling finding |
| CNA1 | Certified Nurse Aide | Named in soiled linen handling finding |
| OT | Occupational Therapist | Named in therapy and splint use findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to the facility's failure to identify and acknowledge a missing resident (Resident 3) and failure to provide adequate supervision to prevent elopement, resulting in immediate jeopardy to resident health and safety.
Findings
The facility neglected to timely implement emergency protocols when Resident 3 went missing and failed to provide adequate supervision to prevent the resident's elopement. The resident was mistakenly taken by transport instead of the intended resident and was found offsite at a local Waffle House. The facility provided an acceptable Immediate Jeopardy Removal Plan and corrective actions including staff re-education, implementation of a porch pass system, and enhanced monitoring.
Complaint Details
The complaint investigation revealed that Resident 3 was missing from the facility on 11/04/24 and was not reported as missing within 30 minutes as required. The resident was mistakenly taken by transport instead of the intended resident and was later found at a local Waffle House. The facility failed to initiate a Code White or emergency response timely. Immediate Jeopardy was cited related to abuse, neglect, and quality of care. The facility submitted an acceptable IJ Removal Plan and was found to be in past non-compliance as of 11/07/24.
Severity Breakdown
Immediate jeopardy: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect residents from all types of abuse including neglect by not acknowledging a missing resident and not implementing emergency protocols timely. | Immediate jeopardy |
| Failure to provide adequate supervision to prevent elopement of Resident 3. | Immediate jeopardy |
Report Facts
Date of resident missing: Nov 4, 2024
BIMS score: 8
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Reported no urgency or Code White initiated when Resident 3 was missing. |
| Director of Nursing | DON | Reported Resident 3 left with transport instead of intended resident and no Code White was initiated. |
| Assistant Director of Nursing | ADON | Was supposed to escort intended resident to appointment but left before him and was unaware of missing resident. |
| Administrator | Administrator | Notified late about missing resident and stated she would have locked down the building if informed earlier. |
| Social Services Director | SSD | Clarified decisional capacity form for Resident 3 and noted conflicting medical record information. |
Inspection Report
Annual Inspection
Deficiencies: 10
Mar 15, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey and extended survey to assess compliance with federal regulations related to resident rights, care, safety, medication administration, staffing, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, inadequate provision of clean linens, failure to provide timely discharge notifications, incomplete implementation of care plans, inadequate assistance with activities of daily living, improper wound care, unsafe smoking practices with immediate jeopardy identified, insufficient RN staffing, and medication storage and administration errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure Resident (R)30 was afforded the right to formulate an advance directive. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide clean linen/washcloths to residents throughout the facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident (R)30 or his personal representative received timely discharge notification upon hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement interventions outlined in Resident (R)53's care plan related to fall prevention. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care, maintain personal hygiene, and provide showers for Resident (R)44 requiring extensive assistance with ADLs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow proper wound care procedure for Resident (R)85 to promote healing and reduce infection risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct smoking assessments for 4 residents who smoke and failed to provide proper safety protocols for 10 residents who smoke, resulting in Immediate Jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide sufficient Registered Nurse staffing on a 24-hour basis to ensure adequate resident care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication administration error rate was less than 5 percent; insulin pens were primed and administered incorrectly for Residents (R)100 and R14. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly label and store medications and biologicals, including failure to date opened medications, presence of loose pills in medication carts, and expired medications in storage rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration error rate: 8
Days without RN coverage for 8 consecutive hours: 28
Residents identified as smokers without smoking assessments: 4
Residents with improper smoking safety protocols: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Failed to correctly prime and administer insulin pen to Resident R100 |
| LPN3 | Licensed Practical Nurse | Failed to correctly prime insulin pen and administer insulin to Resident R14 |
| Director of Nursing | Director of Nursing | Interviewed regarding missing advance directives, discharge notifications, wound care, smoking policies, staffing, and medication storage |
| Administrator | Administrator | Interviewed regarding smoking policies and staffing |
| LPN8 | Licensed Practical Nurse | Unaware of medication storage issues and discarded expired/unlabeled items |
| LPN5 | Licensed Practical Nurse | Confirmed medication cart issues and discarded loose pills and unlabeled insulin pen |
| LPN9 | Licensed Practical Nurse | Confirmed unlabeled insulin pen and discarded it |
| CNA2 | Certified Nursing Assistant | Interviewed about shower provision and nail care |
| CNA3 | Certified Nursing Assistant | Interviewed about nail care protocol |
| LPN1 | Licensed Practical Nurse | Interviewed about personal hygiene care and shower documentation |
| CNA4 | Certified Nursing Assistant | Interviewed about personal hygiene care documentation |
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 24, 2023
Visit Reason
The inspection was conducted following complaints and allegations regarding confidentiality breaches of resident medication records and misappropriation of resident trust funds, as well as medication administration and storage issues.
Findings
The facility failed to maintain confidentiality of resident medication records, misappropriated $7,900 from a resident's trust fund without proper consent or documentation, failed to conduct a thorough investigation of the misappropriation, did not administer medications on time for multiple residents, and failed to securely store medications and treatment carts on one resident hall.
Complaint Details
The complaint investigation was triggered by allegations from the daughter of Resident R7 regarding unauthorized withdrawals totaling $7,900 from the resident's trust fund account, including a $6,000 check purportedly for funeral arrangements that were not authorized or verified. The facility failed to follow its Resident Trust Fund policy, lacked proper signatures on withdrawals, and did not complete reimbursement. A police report was filed and a criminal investigation was ongoing. The facility's investigation was incomplete and corporate office took over further follow-up.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to assure confidentiality of resident medication records on 1 of 4 resident halls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from misappropriation of funds; specifically, $7,900 missing from Resident R7's trust fund account. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform a complete and thorough investigation regarding missing funds from resident trust fund accounts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were administered on time for 3 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assure that medications were securely stored on 1 of 4 resident halls; observed unlocked and unattended medication and treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Amount misappropriated: 7900
Amount withdrawn: 6000
Amount withdrawn: 1900
Date of survey completion: Apr 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Verified medication cart screen confidentiality breach and unlocked treatment cart belonging to respiratory therapy | |
| Licensed Practical Nurse (LPN)2 | Interviewed regarding late medication administration on 04/24/23 | |
| Licensed Practical Nurse (LPN)3 | Verified unlocked and unattended wound care treatment cart on 04/26/23 | |
| Administrator | Conducted investigation of Resident R7's trust fund misappropriation, reported to SCDHEC, communicated with corporate office and police, and provided updates during survey | |
| Business Office Manager | Referenced as having audit information and involved in investigation follow-up; unavailable for interview | |
| Previous Business Office Manager | Unable to provide receipt for $6000 check and unavailable for interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify the responsible party of a resident's change in condition related to acquiring multiple pressure ulcers.
Findings
The facility failed to notify the responsible party for Resident 2 in a timely manner about the development of multiple pressure ulcers. Documentation showed pressure areas on the resident's buttocks and sacral area, but no evidence of notification to the resident's representative was found.
Complaint Details
The complaint investigation found that the responsible party for Resident 2 was not notified at any time of the skin breakdown on the resident's buttocks and sacral area.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the responsible party of a resident's change in condition related to acquiring multiple pressure ulcers in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Body audit dates: 6
Inspection Report
Annual Inspection
Deficiencies: 4
Mar 4, 2022
Visit Reason
The inspection was conducted as a standard regulatory survey to assess compliance with care planning, wound care, respiratory care, and facility sanitation standards.
Findings
The facility failed to develop comprehensive person-centered care plans for multiple residents, did not follow physician orders for wound care for one resident, failed to ensure respiratory equipment was properly stored, and did not maintain the outside garbage area clean and contained, increasing risks to resident safety and infection control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, including tracheostomy care and use of side rails for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders for wound care were followed, resulting in treatment errors for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure respiratory equipment was bagged when not in use, increasing risk of contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the outside garbage area was clean and garbage contained, with overflowing dumpsters and trash on the ground. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 33
Residents affected by care plan deficiency: 6
Residents affected by wound care deficiency: 1
Residents affected by respiratory care deficiency: 1
Residents affected by garbage disposal deficiency: Many
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in wound care treatment error finding |
| LPN 3 | Licensed Practical Nurse | Named in care plan deficiency for side rails |
| LPN 5 | Licensed Practical Nurse | Named in respiratory equipment storage deficiency |
| MDS Coordinator | Confirmed missing care plan information | |
| MDS Nurse | Confirmed missing care plan information | |
| Administrator | Confirmed expectations for care plans and respiratory equipment storage | |
| Director of Nursing | Confirmed expectations for care plans, wound care orders, and respiratory equipment storage | |
| RT 6 | Respiratory Therapist | Confirmed respiratory equipment storage procedures |
| Kitchen Manager | Interviewed regarding garbage disposal and trash area conditions | |
| Maintenance Assistant | Interviewed regarding trash pickup responsibilities | |
| Maintenance Director | Interviewed regarding trash pickup and dumpster maintenance | |
| Housekeeping Supervisor | Interviewed regarding trash disposal and cleanup responsibilities |
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