Inspection Reports for The Brian Center Nursing Care – St. Andrews
3514 Sidney Rd, Columbia, SC 29210, United States, SC, 29210
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
171% worse than South Carolina average
South Carolina average: 3.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 8
Jul 17, 2025
Visit Reason
The inspection was conducted as part of a recertification and complaint survey to assess compliance with regulatory requirements and to investigate specific complaints related to resident care and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, delayed baseline care plans, improper tube feeding administration, inadequate respiratory care equipment sanitation, expired and unlabeled medications, improper food storage practices, ineffective quality assurance processes, and lack of a comprehensive infection prevention and control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure resident assessments accurately reflected pressure ulcer status for 1 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely develop a baseline care plan within 48 hours of admission for 1 of 7 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with continuous tube feed received the correct ordered amount and rate and failed to label and date tube feed bag for 1 of 1 resident reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care; nebulizer machine, oxygen mask, and medication chamber were not clean or bagged for 1 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove expired and discontinued medications and failed to label and date open medications in 3 of 6 medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure foods stored in freezer, refrigerator, and dry storage were sealed, labeled, dated with use-by dates, and discarded after expiration in 1 of 1 kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement effective corrective actions through the quality assurance and performance improvement (QAPI) committee to address previously identified deficiencies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program with proper surveillance and documentation for 2024 and early 2025. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts inspected: 6
Residents: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Confirmed incorrect tube feeding rate and improper nebulizer mask handling |
| LPN3 | Licensed Practical Nurse | Confirmed expired medications on medication cart |
| LPN4 | Licensed Practical Nurse | Confirmed expired tube feeding formula and unlabeled insulin pen |
| Director of Nursing | Director of Nursing (DON) | Provided statements on assessment responsibilities, medication disposal authority, and infection control program |
| MDS Coordinator | Minimum Data Set Coordinator | Responsible for completing MDS assessments and acknowledged inaccurate documentation of pressure ulcer |
| Dietary Manager | Dietary Manager | Provided information on food storage expectations and kitchen management |
| Administrator | Facility Administrator | Discussed QAPI committee effectiveness and kitchen oversight |
| Regional Clinical Nurse | Regional Clinical Nurse | Discussed antibiotic review and infection tracking |
| Infection Preventionist | Infection Preventionist | Described infection identification and surveillance practices |
| Unit Manager | Unit Manager | Provided information on oxygen order verification |
Inspection Report
Complaint Investigation
Deficiencies: 6
Apr 29, 2025
Visit Reason
The inspection was conducted due to allegations of potential non-consensual sexual abuse involving Resident R1 and Resident R2, as well as concerns about the facility's response to these allegations and the safety of other residents.
Findings
The facility failed to protect residents from abuse, specifically failing to prevent and properly respond to a non-consensual sexual encounter involving Resident R1 and Resident R2. The facility did not timely report the incident to proper authorities, failed to adequately investigate, and did not protect residents from further risk. Additionally, the facility failed to monitor psychotropic medication use appropriately and did not maintain safe water temperatures, placing residents at risk of scalding.
Complaint Details
The complaint involved allegations of non-consensual sexual abuse by Resident R1 against Resident R2. Multiple residents and staff reported incidents of R1 entering R2's room without consent and inappropriate touching. The facility failed to report the incident timely to authorities, failed to protect residents, and did not adequately investigate or notify the resident representative. Immediate Jeopardy was cited due to these failures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure residents were treated with dignity and respect after a potential non-consensual sexual encounter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a non-interviewable, cognitively impaired resident from a non-consensual sexual encounter, resulting in Immediate Jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to monitor psychotropic medication use appropriately for Resident R1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement abuse policies regarding investigation, reporting, and prevention of sexual abuse allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and notify proper authorities, resulting in Immediate Jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to maintain water temperatures within safe limits, placing residents at risk for scalding injuries. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of survey completion: Apr 29, 2025
BIMS score: 15
BIMS score: 13
BIMS score: 7
Water temperature: 132
Water temperature: 131.1
Water temperature: 122.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Reported concerns about sexual abuse and gave written statement to Administrator and DON. |
| LPN2 | Licensed Practical Nurse | Reported incidents of R1 entering female residents' rooms and notified unit manager. |
| CNA1 | Certified Nursing Assistant | Assigned to R1 for 1:1 supervision and reported prior wandering behavior. |
| CNA2 | Certified Nursing Assistant | Observed R1 in R2's room and redirected him; unsure if R2 was evaluated. |
| CNA3 | Certified Nursing Assistant | Aware of abuse policy and reported R1 wandering behavior. |
| CNA4 | Certified Nursing Assistant | Observed multiple incidents of R1 wandering into R2's room and reported to LPN1. |
| Unit Manager | Unit Manager | Reported incident to Administrator and described investigation process. |
| Administrator | Facility Administrator | Responsible for corrective action plan and reported to law enforcement. |
| DON | Director of Nursing | Involved in investigation and education of staff on abuse policies. |
| PNP | Psychiatric Nurse Practitioner | Evaluated Resident R1 and recommended psychotropic medications. |
| MD | Medical Director | Notified late about abuse incident and psychotropic medication monitoring. |
| POD | Plant Operations Director | Measured unsafe water temperatures and adjusted mixing valve. |
| SW | Social Worker | Reported resident concerns to Administrator and was informed incident was being handled. |
Inspection Report
Routine
Census: 31
Deficiencies: 8
Jan 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at the same table, lack of a comprehensive dementia care plan for a resident, inadequate fingernail care for a dependent resident, failure to provide ordered orthotic devices, incomplete documentation of dialysis care, insufficient monitoring of psychotropic medication side effects, serving cold food to residents in rooms, and failure to maintain cleanliness in medication storage areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to serve meals to residents eating at the same table at the same time, affecting dignity and well-being. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan for dementia for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide fingernail care services to a resident dependent on staff for activities of daily living. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident received ordered orthotic devices (bilateral palm protectors) to maintain range of motion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document resident's condition upon return from dialysis treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately monitor residents on psychotropic medications for side effects and behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food at a safe and appetizing temperature; residents in rooms received cold food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication storage room refrigerator and sink were clean. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 6
Census: 31
Temperature: 113
Temperature: 112
Temperature: 109
Facility census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Confirmed lack of dementia care plan and dialysis documentation |
| Dietary Manager | Dietary Manager | Interviewed regarding meal service and food temperature |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided expectations for meal service and confirmed deficiencies |
| Social Services Director | Social Services Director | Confirmed lack of dementia care plan |
| Director of Nursing | Director of Nursing | Confirmed expectations for dementia care plan, dialysis documentation, and medication monitoring |
| Certified Nursing Assistant 7 | Certified Nursing Assistant | Interviewed regarding fingernail care provision |
| Rehabilitation Director | Rehabilitation Director | Provided information on orthotic device education and use |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding orthotic device application and medication room cleaning |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Commented on medication room cleanliness |
| Administrator | Facility Administrator | Acknowledged food temperature issues and expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 12, 2023
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's failure to properly document and secure the destruction of controlled substances, specifically Tramadol, for one resident.
Findings
The facility failed to follow proper procedures for destruction of controlled substances by not documenting the final count and improperly securing Tramadol medication. The medication was misplaced after being removed from the locked narcotic destruction box, and staff were re-educated on medication destruction procedures.
Complaint Details
The complaint investigation revealed that the facility could not locate the discontinued Tramadol medication for Resident 4 after it was removed from the locked narcotic destruction box. Interviews with nursing staff indicated improper handling and storage of the medication, and the Director of Nursing and staff were unable to locate it despite searching.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow destruction of controlled substances by documenting the final count of Tramadol and locking it up to be destroyed for 1 of 1 resident reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Tramadol pills in cart to be destroyed: 15
Residents reviewed for medication destruction: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Unit Manager | Interviewed regarding handling and storage of Tramadol medication |
| LPN2 | Mentioned as handing controlled substance to LPN1 and unavailable for interview | |
| Director of Nursing | DON | Interviewed regarding medication destruction procedures and investigation of missing Tramadol |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 28, 2023
Visit Reason
The inspection was conducted due to a complaint regarding inadequate wound care for Resident 4 (R4), specifically failure to provide necessary treatment for a pressure ulcer, which resulted in hospitalization.
Findings
The facility failed to ensure appropriate pressure ulcer care and prevention of new ulcers for R4. The wound was not properly assessed, documented, or treated upon admission, leading to deterioration and hospitalization. The facility was unable to provide R4's admission Skin Assessment/Braden Skin Risk Assessment.
Complaint Details
The complaint investigation revealed that R4's sacrum wound was not properly assessed or treated, leading to a strong odor and subsequent discharge to the hospital. Interviews with the Resident Representative, Director of Nursing, and Administrator confirmed the failure to assess and treat the wound upon admission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary wound treatment for a pressure ulcer resulting in hospitalization of Resident 4. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Wound measurements: 0.5
Wound measurements: 0.4
Wound measurements: 0.2
Wound measurements: 8.5
Wound measurements: 7.5
Wound measurements: 0.1
Wound measurements: 10.5
Wound measurements: 13.5
Wound measurements: 0
Brief Interview of Mental Status (BIMS) score: 99
Assessment Reference Date: Aug 3, 2022
Hospital discharge date: Jul 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to assess, document, and treat R4's sacrum wound upon admission |
| Administrator | Administrator | Interviewed regarding inability to provide R4's admission Skin Assessment/Braden Skin Risk Assessment |
Inspection Report
Annual Inspection
Deficiencies: 14
Oct 28, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to honor residents' rights regarding advance directives, failure to provide privacy for telephone calls, inadequate supervision leading to resident elopement, failure to prevent and investigate abuse, incomplete PASARR screening, incomplete care plans for psychotropic medication use, improper wound care, inadequate nutrition interventions, medication administration errors, incomplete medication documentation, and malfunctioning call light system.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure residents were afforded the right to formulate an Advance Directive. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide personal privacy for residents when making phone calls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent elopement of a resident with dementia. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft; failed to report and investigate abuse allegations timely and thoroughly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide the Pre-admission Screening and Annual Resident Review (PASARR) for mental illness and intellectual disability for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan addressing the use of antipsychotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a nutrition prevention intervention plan to prevent significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication administration error rate was less than 5%. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were labeled and stored properly; failed to remove expired medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure electronic Medication Administration Record (MAR) was complete and accurate, including documentation of controlled medications and pain assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain and ensure the call light system was properly working for a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 17.86
Weight loss percentage: 11.2
Residents affected: 12
Residents affected: 5
Residents affected: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN4 | Registered Nurse | Provided statement regarding resident elopement incident. |
| CNA3 | Certified Nursing Assistant | Provided statement regarding resident elopement incident. |
| LPN3 | Licensed Practical Nurse | Administered medications with errors; failed to prime insulin syringe and shake inhaler. |
| LPN5 | Licensed Practical Nurse | Confirmed expired medication found in medication storage room. |
| RN1 | Registered Nurse | Administered Lovenox incorrectly and massaged injection site. |
| LPN6 | Licensed Practical Nurse | Discussed pain medication documentation and administration. |
| LPN8 | Licensed Practical Nurse | Discussed resident pain and medication administration. |
| Administrator | Provided information on abuse incidents, medication errors, and elopement. | |
| Director of Nursing | Director of Nursing | Acknowledged failures in supervision, abuse investigation, and medication documentation. |
| Social Worker | Social Worker | Discussed PASARR screening and care plan responsibilities. |
| MDS Coordinator | MDS Coordinator | Discussed care plan omissions for psychotropic medication. |
| Maintenance Supervisor | Maintenance Supervisor | Verified malfunctioning call light and maintenance log issues. |
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