Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 10, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision leading to resident falls, failure to provide appropriate respiratory care per physician orders, and improper food storage and labeling practices.
Findings
The facility failed to ensure adequate supervision to prevent falls for Resident 4, failed to clarify CPAP therapy mode and settings for Resident 1, and failed to properly label and store opened food items in two kitchens. Multiple interviews and record reviews confirmed these deficiencies.
Complaint Details
The complaint investigation revealed that Resident 4 experienced two falls due to staff not following the care plan requiring two-person assistance. Interviews with the resident, resident representative, CNA, therapy staff, and administration confirmed inadequate staffing and failure to provide required assistance. The respiratory care complaint involved failure to clarify CPAP settings in physician orders for Resident 1, confirmed by multiple nursing and therapy staff interviews. The food storage complaint involved observations of unlabeled opened food items and improper storage of personal items in kitchen areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure Resident 4 had adequate supervision to prevent a fall, including failure to provide two-person assist as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care by not clarifying Resident 1's CPAP Support Therapy mode and settings in physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure opened food items were properly labeled and stored in accordance with professional standards in two kitchens. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 3
BIMS score: 15
BIMS score: 7
Date of survey completion: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA5 | Certified Nursing Assistant | Named in fall incidents involving Resident 4 |
| Physical Therapy Assistant | PTA | Named in fall incident involving Resident 4 and re-education |
| Licensed Practical Nurse 1 | LPN | Provided information on CPAP care for Resident 1 |
| Nurse Practitioner | NP | Interviewed regarding CPAP policy and Resident 1 care |
| Registered Nurse 3 | RN | Interviewed regarding CPAP care for Resident 1 |
| Director of Nursing | DON | Interviewed regarding fall incidents and CPAP order clarification |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and labeling deficiencies |
| Kitchen Manager | Kitchen Manager | Interviewed regarding food labeling and storage practices |
Inspection Report
Annual Inspection
Census: 16
Deficiencies: 4
May 18, 2023
Visit Reason
The inspection was conducted as part of the facility's annual regulatory compliance review to assess care plan development, medication storage and labeling, food safety, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to revise comprehensive care plans for residents with pressure ulcers, improper storage and labeling of medications and food, inadequate cleaning of the ice machine, and failure to properly track and trend antibiotic use and infections.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to revise the comprehensive care plan for Resident 17 after identification of a stage three pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure narcotics were stored in a permanently affixed locked compartment and discontinued narcotics were not secured properly while awaiting destruction; insulin pens in use were not dated with open and expiration dates. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored and labeled properly in dry goods storage, walk-in fridge, and walk-in freezer; ice machine was not properly cleaned and had pink/brown residue. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an antibiotic stewardship program that monitors antibiotic use, with missing documentation for six of twelve months reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 16
Medication quantities: 12
Insulin pens: 4
Months missing antibiotic stewardship documentation: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Interviewed regarding care plan update responsibilities and wound identification | |
| LPN2 | Interviewed regarding wound identification and notification to provider | |
| MDS Coordinator | Responsible for updating care plans; interviewed about care plan deficiencies | |
| Director of Nursing | DON | Confirmed medication storage issues, care plan update expectations, and antibiotic stewardship responsibilities |
| Administrator | Interviewed regarding expectations for care plan updates, food storage, ice machine cleaning, and antibiotic stewardship | |
| Executive Chef | EC | Interviewed and observed food storage and ice machine cleanliness issues |
| Registered Nurse | RN1 | Provided information about insulin pen expiration dates |
| Infection Control Coordinator | Interviewed regarding antibiotic stewardship program and missing documentation |
Inspection Report
Annual Inspection
Deficiencies: 6
Dec 9, 2021
Visit Reason
The inspection was conducted as a comprehensive annual survey of Wildewood Downs nursing home to assess compliance with regulatory requirements across multiple areas including respiratory care, pain management, medication and supply storage, food service, infection control, and equipment maintenance.
Findings
The facility was found deficient in several areas including failure to provide safe respiratory care by not changing oxygen tubing and humidifiers per orders, inadequate pain management for a resident, failure to remove expired supplies and properly label medications, poor kitchen sanitation and food safety practices, failure to implement effective COVID-19 visitor screening, and failure to maintain essential equipment such as the dishwasher and garbage disposal in safe working condition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure oxygen tubing and humidifier were changed per physician orders for a resident on oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to effectively manage and prevent a resident's pain consistent with assessment and care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired supplies were removed from resident treatment areas and medications properly labeled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen cleanliness, proper food labeling, and staff hygiene including facial hair covers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure ongoing COVID-19 screening for visitors at the facility entrance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain essential equipment including dishwasher and garbage disposal in safe working condition. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 20
Residents affected: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding oxygen tubing and humidifier change |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding pain medication administration |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed regarding resident pain complaint |
| Director of Nursing | Director of Nursing | Interviewed regarding pain medication and expired supplies policy |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding expired supplies and pain medication |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Responsible for checking expired supplies |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed regarding COVID-19 visitor screening |
| Registered Nurse 1 | Registered Nurse | Interviewed regarding COVID-19 visitor screening and expired supplies |
| Certified Dietary Manager | Certified Dietary Manager | Confirmed kitchen sanitation deficiencies |
| Foodservice Consultant | Foodservice Consultant | Interviewed regarding kitchen equipment and sanitation issues |
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