Conway Manor

F-F686, constituting substandard quality of care.

Findings include:

Review of the facility policy titled, Skin Management System revised on 01/2025, documented It is the policy of this facility that any resident .or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. 5. A report of all wounds and their progress will be updated by the treatment nurse weekly.

Review of Resident R103's Face Sheet revealed Resident R103 was admitted to the facility initially on 06/19/24, with a readmission on 10/28/24, with diagnoses including but not limited to: pressure ulcer of right heel- stage 4, osteomyelitis, ankle and foot, methicillin resistant staphylococcus aureus infection as the cause.

Review of Resident R103's Physician Orders dated 09/30/24 revealed, paint right heel with betadine, cover with ABD pad, every day shift for wound healing; cleanse right heel with dakins, apply mesalt and border every day shift for wound healing.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 425121 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425121 B. Wing 02/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak View Health and Rehabilitation 3300 4th Avenue Conway, SC 29527

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of Physician Orders dated 10/03/24, revealed, cleanse right hell with Dakins solution and apply Mesalt and border gauze every day shift for wound healing and as needed. Level of Harm - Immediate jeopardy to resident health or Review of Resident R103's Progress Notes dated 10/03/24, documented, During report nurse stated resident has safety maggots in right heel wound.

Residents Affected - Few Review of Nurses Notes dated 10/03/24 at 7:10 PM, revealed, Doctor notified and new orders to send resident out for further evaluation.

Review of pictures and videos provided by staff, of the wound and maggots, revealed a gauze soaked with a wet brown substance and maggots in the wound on the heel of the resident, with the center of the wound dark brown and white surrounding. Maggots were also observed moving on the bed beside the resident's foot.

Review of Resident R103's Hospital Discharge Documentation timestamped with a service date/time of 10/28/2024 at 1419 EDT indicated, Patient is an 89 y/o male with Hypertension and cartoid artery stenosis was sent from nursing home because the staff there noticed maggots on a right heel wound .

During an interview on 02/04/25 at 11:24 AM, Resident R103 revealed that he has wounds on both heels and they were only blisters when he was admitted to the facility. Resident R103 stated that his left heel had maggots in it (later confirmed to be the right heel). Resident R103 explained that he is not sure how the maggots got in the wound, but he knows if a fly lands on it, it lays eggs. Resident R103 further revealed that he went to the hospital and stated, they flushed them out at the hospital.

During an interview on 02/06/25 at 10:18 AM, Licensed Practical Nurse (LPN)8, revealed Resident R103 has two pressure ulcers that are on both heels. Wound care rounds are done every week and wound care is done on Mondays, Wednesdays, and Fridays, I think. LPN8 stated, The wound doctor comes once a week. Resident R103 wasn't admitted initially on this unit, so not sure if he was admitted with the wounds. The wounds were present when Resident R103 was transferred to this unit. Maggots were in the wound before he came to this unit. LPN8 further revealed, The treatment for Resident R103's wound is to clean the wound, apply hydrofera blue, and a border gauge, not wrapped with anything. LPN8 further revealed that Resident R103 has an order for heel boots and

he only wears them in bed, but when he is in his wheelchair, he likes a pillow under his feet over the foot rest.

During a telephone interview on 02/06/25 at 11:14 AM, LPN6 revealed that she is familiar with Resident R103 and confirmed there were maggots in his wound. LPN6 explained that when she came on shift she was informed by the nurse on day shift that the resident had maggots in his wound and she inquired with the nurse of what

they were going to do about it. She then stated that the day shift nurse informed her that she had called the Assistant Director of Nursing (ADON) and Registered Nurse (RN)3 and was told to only dress the wound and not to clean it or do anything else. LPN6 stated that her response was that she was not going to allow that, therefore she called the DON, who informed her that she wasn't aware of the situation and advised her to call the doctor. LPN6 states that she called the doctor (whose name she could not recall) and the doctor told her to send the resident out to the ER, since they were not there to look at it. LPN6 stated she called 911. LPN6 further explained that although she had worked with the resident days before the discovery of the maggots, she was not aware that the resident had any wounds because wounds were taken care of during

the day and she didn't have to do anything with them. LPN6 revealed that Certified Nursing Assistant (CNA)1 stated that it had been going on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 425121 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425121 B. Wing 02/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak View Health and Rehabilitation 3300 4th Avenue Conway, SC 29527

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview on 02/06/25 at 1:40 PM, the ADON revealed that she was not aware of maggots in Resident R103's wound. The ADON states I believe we saw him on Wednesday during rounds with the wound doctor Level of Harm - Immediate and there was nothing unordinary with the wound and he was sent out a day or two later. The ADON jeopardy to resident health or continued to explain that a nurse, either the floor nurse or the unit manager called her to inquire if there was safety a change in the resident's treatment plan and she further explained that she believed that at that time the treatment was Dakins wet to moist. The ADON further states no one told me about maggots. Residents Affected - Few

During an interview on 02/06/25 at 3:06 PM, LPN7 revealed she was doing a dressing change with the assistance of a CNA and this was her first time working with the resident and the CNAs. LPN7 explained that when she saw the bugs, that appeared to be maggots in the resident's wound and she took a picture of just

the resident's foot and sent it to RN3 via text seeking advice on how to treat. LPN7 stated that she was told that the resident had a history of parasitic infections and to treat the wound with Dakin's and dress it as best

she could and that the wound nurse, who is also the ADON would take care of it the next morning when she comes in and for her not to chart it. LPN7 further explained that this incident happened around 6 PM, there was no Dakin's on hand, and she reported the incident to the night nurse when she came in. LPN7 states that she ended her shift at 7 PM and later texted the DON around 9 PM, after arriving home, to inform her of what happened. LPN7 further explains that when she saw the maggots it was only about 3-5, there was no date on the dressing she was removing, so she wasn't sure how long the dressing had been on the resident, and that the resident didn't appear to be in any pain or distress. LPN7 further revealed that she was informed that by the time the night nurse sent the resident out, the wound was swarming with maggots.

During an interview on 02/07/25 at 10:53 AM, RN3 revealed that she is unable to recall the exact day but stated it was late in the day because she had already left the building. RN3 stated that she was made aware that Resident R103 had maggots in his wound, when she received a call from LPN7 stating that she was doing a dressing change and saw maggots in the resident's wound. RN3 stated that she received a picture of the wound with maggots from LPN7 and she then sent the photo to the ADON, who is also the wound care nurse, and the ADON confirmed to her that she could see them in the photo. RN3 stated that she was not able to see the maggots at first but then zoomed in and was able to see them. RN3 stated that the ADON advised her to instruct LPN7 to clean the wound with Dakins wet to dry and change the dressing. RN3 further explains that by this time she was communicating back and forth with LPN7 and the ADON, and the ADON was communicating back and forth with the DON.

During an interview on 02/07/25 at 11:28 AM, the DON revealed that she could not recall the exact conversation, and she was going by the notes entered, that it was alleged that Resident R103 had maggots in his wound. The DON explained that she received a call from the ADON stating that she was getting an order to change the treatment and then she received a call from the night nurse informing her that she received a report that Resident R103 had maggots in his wound and she had called the physician and was sending him out to the hospital. The DON stated that Resident R103 was sent out the hospital and the hospital never verified there were any maggots in the wound.

The following measures were immediately implemented upon notification of the facility:

1. Corrective action for residents found to have been affected by this deficiency:

a. Resident R103 was found to be affected by the alleged deficient practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 425121 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425121 B. Wing 02/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak View Health and Rehabilitation 3300 4th Avenue Conway, SC 29527

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 b. On 10/3/2024 at 6:50 pm LPN received report on Resident R103. At 7:05 pm LPN notified physician of findings. Order was received to send resident to emergency room for evaluation. At 7:30 pm EMS was called and at Level of Harm - Immediate 7:50 resident left the facility with EMS. jeopardy to resident health or safety c. On 10/4/2024 Director of Nursing Services reviewed Resident R103 TAR (treatment administration record) for September 2024 and October 2024. Treatment administered per order. Residents Affected - Few 2. Corrective action for residents that may be affected by the deficiency:

a. Residents with wounds have the potential to be affected by the alleged deficient practice.

b. On 10/4/2024 an audit of all wounds was completed by Assistant Director of Nursing (RN) and Unit Manager (RN). No changes were noted to any of the wounds.

c. On 10/4/2024 all direct care licensed nurses received wound care education.

d. On 10/4/2024 maintenance director completed facility wide observation for pests, insects, or any related issues. No issues were identified.

e. Although no issues were identified during maintenance audit, facility administrator wanted to ensure every intervention was implemented due to the seriousness of the allegation. On 10/4/2024 maintenance director contacted Terminix and requested an additional preventative visit and facility administrator ordered air curtain fans for all high traffic doors.

3. Other Plan of removal actions:

a. The Medical Director was notified of the IJ on 02/07/2025 at 4:30 pm.

b. An adhoc QAPI meeting regarding the items in the IJ template completed on 02/07/2025. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.

c. Wound care education is included as part of the annual skills fair and new hire orientation for all licensed nurses.

d. Maintenance Director completed weekly audits x8 weeks (10/10/24-11/29/2024) of facility for presence of insects, pests, or any other related issues.

e. Registered nurses on nursing management team completed weekly audits x 8 weeks (10/10/24-11/29/2024) of wounds for any changes in condition.

f. Findings were reported to QAPI committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.

g. The aforementioned incident was self-reported and subsequently cleared without citation on 12/4/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 425121