Conway Manor

F-F578. Implementation of the removal plan was verified on [DATE REDACTED] at 11:15 AM. The IJ was verified to be removed as of [DATE REDACTED].

Findings Include:

Review of the facility's policy titled, Care and Treatment, Subject: Advance Directives, revised ,d+[DATE REDACTED] revealed Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.

Review of Resident R424's electronic medical record (EMR) revealed his code status orders were CPR/Full Code- no tube feed effective [DATE REDACTED]. Resident R424's care plan reflects Full Code status. Resident R424's EMR contained a paper Emergency Medical Services Do Not Resuscitate Order signed by Resident R424's Responsible Party (RP) and a physician on [DATE REDACTED] requesting DNR status. There was also a Physician order dated [DATE REDACTED] at 1845 for DNR, which was signed by a Nurse and a Physician.

On [DATE REDACTED] at 12:16 PM, Resident R424, who had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate intact cognition stated, I want to die, I don't want them to save me.

During a telephone interview on [DATE REDACTED] at 12:30 PM, Resident R424's RP confirmed Resident R424 wishes to be a DNR.

During an interview on [DATE REDACTED] at 2:15 PM with Licensed Practical Nurse (LPN)1 and Registered Nurse (RN)1, they stated, If there was a code, we would go to PointClickCare (PCC) and verify the code status. We will check vitals and start CPR. We then would call out for a Code Blue and then continue to monitor with CPR until EMS comes and takes over.

During an interview with LPN2 on [DATE REDACTED] at 2:19 PM, she stated in order to verify code status, she would check the EMR. When asked to confirm Resident R424's code status, LPN2 went into the EMR and stated he was a Full Code.

During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 2:30 PM, she stated she would look under the MISC tab in the EMR for the code status and look at the doctor ' s orders. If a resident was not breathing, they would call a code blue .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 27 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 0578 During an interview with the Minimum Data Set (MDS) Nurse on [DATE REDACTED] at 3:20 PM, she stated the care plan should be updated related to the Resident's Physician's orders. Level of Harm - Immediate jeopardy to resident health or During a consecutive interview with the DON on [DATE REDACTED] at 3:32 PM, she confirmed Resident R424 had conflicting safety code statuses' and she would need to look into it.

Residents Affected - Few Review of the facility plan of removal included the following:

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

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

-Resident #424 preferred level intensity was reviewed with responsible party and order was corrected in point click care (PCC).

2. Corrective action for residents that may be affected by the deficiency:

-The Medical Director was notified of the IJ on [DATE REDACTED] at 4:39 PM.

-All residents have the potential to be affected by the deficient practice.

-On [DATE REDACTED] at 4:30 PM to 8:00 PM, a full house audit of current residents was reviewed by the Director of Nursing and validated that preferred level of intensity and signed DNR order matches the order in PCC and care plan. No other residents were identified to be affected by the alleged deficiency.

3. Other Plan of Removal Actions:

-On [DATE REDACTED] at 4:15 PM, an in-service was prepared by the DON and initiated by the Assistant Director of Nursing (RN) for all licensed nurses, medical records personnel, and social services employees. The in-service included the advanced directives policy and how to transcribe orders correctly.

-Education will be included as part of the annual skills fair and new hire orientation for licensed nurses, medical records personnel, and social services employees.

-An ad hoc meeting regarding the items in the IJ template completed [DATE REDACTED]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.

-Changes in advanced directives will be reviewed daily clinical meeting 5x a week x12 weeks and monitored by Director of Nursing or Designee.

-DON or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.

Date of Compliance: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 27 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 50850 potential for actual harm Based on review of the facility policy, observations, record review, and interviews, the facility failed to provide Residents Affected - Few care and services, specifically heel and ankle protection devices and a wedge cushion for offloading, while in bed per Physician orders, for Resident (R)11.

Findings include:

Review of the facility policy titled, Physician Orders, revised 11/2024 states:

Recording Orders, Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Example: Apply 4 x 4 duoderm with border to stage 1 ulcer to coccyx; change every 3 days and as needed per wound care protocol.

Implementing Orders, 1. Orders should be followed as written. 2. Physician should be notified if order is not followed for any reason.

The facility admitted Resident R11 on 06/27/2007 with diagnoses including, but not limited to, Alzheimer's disease, bipolar disorder, chronic kidney disease, acute kidney failure, psychotic disturbance, mood disturbance, anxiety, anemia and hypothyroidism.

Review of the medical record on 02/06/2025 at 11:00 AM revealed physician orders for 1)bilateral heel boots while in bed every shift with a start date of 01/29/25 at 07:00 PM and a revision date of 01/30/25 and 2) Wedge cushion while in bed every shift with a start date of 01/03/25 at 07:00 PM and a revision date of 01/03/25.

An observations on 02/04/25 at 09:18 AM revealed Resident R11 lying in bed. Bilateral heels were elevated on a pillow, but there are no heel boots present and there was no wedge in the bed as per Physician's orders. An

interview was attempted with Resident R11, however, Resident R11 does not speak, but nods yes or no.

An observations on 02/04/25 at 02:20 PM revealed Resident R11 lying in bed. Bilateral heels are elevated on a pillow, but there are no heel boots present and there is no wedge in the bed.

During an interview on 02/07/25 at 01:35 PM with Certified Nursing Assistant (CNA)6 revealed, Resident R11 did not have her heel booties on 02/04/25 and 02/05/25 because I could not find them. I had to go to the linen closet and get her another pair. I did not know about the wedge. I am glad you told me. I will ask about that.

During an interview with Registered Nurse (RN)3 on 02/07/25 at 01:38 PM revealed, My expectation is that

the CNAs ensure that the heel booties are found and on the resident. The heel booties should be washed every three days, unless they are visibly soiled.

During an interview on 02/11/25 at 10:50 AM, the Director of Nursing (DON) stated, She would expect that staff follow Doctor's orders. If the Doctor's order cannot be followed, the Physician should be notified and I should be made aware.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 27 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Immediate 49818 jeopardy to resident health or safety Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)103's wound was properly managed, resulting in Resident R103 acquiring maggots inside the wound bed on the Residents Affected - Few resident's right heel.

On 02/07/25 at 3:18 PM, the Administrator and the Director of Nursing (DON) was notified that the failure ensure Resident R103's wound was properly managed, constituted Immediate Jeopardy (IJ) at

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.

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.

Review of Resident R103's Progress Notes dated 10/03/24, documented, During report nurse stated resident has maggots in right heel wound.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 27 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 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 Level of Harm - Immediate dark brown and white surrounding. Maggots were also observed moving on the bed beside the resident's jeopardy to resident health or foot. safety

Review of Resident R103's Hospital Discharge Documentation timestamped with a service date/time of 10/28/2024 at Residents Affected - Few 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.

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 and there was nothing unordinary with the wound and he was sent out a day or two later. The ADON continued to explain that a nurse, either the floor nurse or the unit manager called her to inquire if there was

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 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 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 Level of Harm - Immediate when she saw the bugs, that appeared to be maggots in the resident's wound and she took a picture of just jeopardy to resident health or the resident's foot and sent it to RN3 via text seeking advice on how to treat. LPN7 stated that she was told safety 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 Residents Affected - Few 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.

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 7:50 resident left the facility with EMS.

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.

2. Corrective action for residents that may be affected by the deficiency:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 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 a. Residents with wounds have the potential to be affected by the alleged deficient practice.

Level of Harm - Immediate b. On 10/4/2024 an audit of all wounds was completed by Assistant Director of Nursing (RN) and Unit jeopardy to resident health or Manager (RN). No changes were noted to any of the wounds. safety c. On 10/4/2024 all direct care licensed nurses received wound care education. Residents Affected - Few 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 11 of 27 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43322 potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure physician order was in place Residents Affected - Few for the use oxygen for Resident (R)219, for 1 of 3 residents reviewed.

Findings include:

Review of the facility policy titled Oxygen Administration - Policy, with an approval date of 01/09/19, documented, Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician .

Review of Resident R219's Face Sheet revealed Resident R219 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: cystitis without hematuria.

Review of Resident R219's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/25, revealed Resident R219 had a Brief Interview for Mental Status (BIMS) score of 12 out of 14 indicating Resident R219 had moderate cognitive impairment.

Review of Resident R219's Physician Orders did not reveal an order for the use of oxygen.

Review of Resident R219's Progress Notes dated 01/20/25, documented, She was comfortably lying in bed with HOB [head of bed] elevated and O2 per nasal cannula.

During an observation on 02/04/25 at an unspecified time, revealed Resident R219 laying in bed receiving oxygen at 3 liters per minute (LPM) via nasal cannula.

During an interview on 02/10/25 at 11:30 AM, Registered Nurse (RN)7 stated, after reviewing the residents orders, There is no active order for oxygen. She shouldn't be on oxygen unless it was an acute situation and even then, we would still get an order. The providers note from the 4th, showed O2 as needed. It doesn't look like the order was transcribed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 50788

Residents Affected - Few Based on interviews and record review, the facility failed to ensure appropriate Registered Nurse (RN) coverage for 8 consecutive hours, daily 7 days a week as required by regulation.

Findings include:

Review of Oakview Health and Rehabilitation Daily Staffing Sheets with a date span of 11/04/24-01/31/25 revealed, the facility did not have appropriate coverage of a RN, 8 consecutive hours daily for the dates of 11/09/24, 12/21/24, 12/22/24, 12/25/24, 01/01/25, 01/04/25, and 01/05/25.

During an interview on 02/06/25 at 10:05 AM, Certified Nursing Assistant (CNA)8 stated, There is never enough staff. Most the of the time, there is one CNA to 9-11 residents and when the census is low, it's about 8-10 residents to one CNA. CNA8 stated she believes that a RN is on duty during the day, but she is not sure. She stated, Shortages are due to turnovers and sickness.

During an interview on 02/06/25 at 11:02 AM, Licensed Practical Nurse (LPN)9 stated, She has no role in staffing, but does try to ensure that staff is here for coverage. LPN9 stated she obtains coverage from the scheduler and if she is unable to obtain coverage, she takes the cart. This happens at least 2-4 times a month. She also stated, sometimes she works as a CNA as well, this happens once every 3 months. LPN9 works 12 hour shifts, all shifts including being on call for weekends. When on call, LPN9 stated, I work wherever the need is. There is usually one LPN and one RN working day shift and two RNs working on the night shift, on alternate days. There has been times when an RN did not work in the Specialty Care Unit

during the night or day. It has never been a time that I can recall, when a RN could not be reached. The Assistant Director Of Nursing (ADON) is contacted and comes in on nights and weekends, if needed.

During an interview on 02/06/25 at 12:52 PM, the Director of Nursing (DON) revealed she oversees the process for staffing. The DON helps solve problems with issues involving staffing and is aware of call offs and help to post shifts with agencies. In the event that the facility cannot obtain coverage, the CNA scheduler helps cover shifts. Unit Managers work together as floor nurses and as CNAs when needed. The Assistant Director of Nursing (ADON) works at this capacity as well and makes the monthly schedule for CNAs. The DON makes the monthly schedules for the licensed nurses. The facility always has RN coverage, even on

the weekends. The DON has not had to cover any medication carts on the floor. The ADON has covered medication carts and has help CNAs as needed.

During an interview with the Administrator on 02/06/25 at 2:30 PM, he provided additional documentation of RN coverage, however, was unable to provide documentation to cover the dates of 11/09/24, 12/21/24, 12/22/24, 12/25/24, 01/01/25, 01/04/25, and 01/05/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 50850 Residents Affected - Many Based on review of the facility policy, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents in 5 of 6 medication carts and 2 of 4 medication rooms.

Findings include:

Review of the facility policy titled, Medication Access and Storage, E kit access with a revision date of 7/2022, states under procedures:

11. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction and reordered from pharmacy, if a current order exists.

12. Any opened vial without an open date will be discarded immediately and replaced with a new vial. Any medication that cannot be verified as to the expiration date, either due to not being dated when opened, or unclear shelf life, shall be discarded immediately and replaced.

Review of the facility policy titled, Administering Medications, with a revision date of 04/2019, states under policy:

12. The expiration/beyond use date on the medication label is checked prior to administering. When opening

a multi-dose container, the date opened is recorded on the container.

An observation and interview on 02/05/25 at 07:40 AM of the Medication Storage Room on the 4th Station revealed the following:

Blood collection tubes with blue top, expired on 12/31/24. Blood Collection tubes with the brown top, expired

on 07/31/24. Protect IV 22 gauge x 1 inch IV Catheter expired on 08/11/24. Ceftriaxone 2 (grams)Gm/50 ml (milliliter) 2 bags, expired 01/21/25. Ceftriaxone 2 Gm/50 ml, 2 bags expired on 01/24/25.

Unit Manager (UM)4, accompanied surveyor during review of 4th station medication room. UM4 verified that

the blood collection tubes, IV catheter, and IV bags of Ceftriaxone were expired. UM4 stated, The expired IV bags are stored in the med room refrigerator, because we have no refrigeration to send the IV bags back to pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 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 0761 An observation and interview on 02/05/25 at 07:50 AM of the 2nd station Medication Storage room revealed

the following: Tresiba Flextouch 200 unit Insulin pen with an open date of 11/01/24. The label states to Level of Harm - Minimal harm or discard after 56 days. Blood collection tubes with blue top, expired on 12/31/24. Blood Collection tubes with potential for actual harm the striped brown top, expired on 12/31/24. 3M Steri-Strip Reinforced Skin Closures, with an expiration date of 10/24. UM2, accompanied surveyor during review of the 2nd station medication storage room. UM2 Residents Affected - Many verified that the blood collection tubes, the Tresiba Flextouch insulin pen, and the Steri-Strip Reinforced Skin Closures were expired.

An observation and interview on 02/05/25 at 09:15 AM of the Medication Cart on 500 hall revealed the following: Vitamin D-3 10 mcg [micrograms] (400 IU) expired 11/24. Lasix 20 mg [milligrams] tablet, expired 02/01/25.

UM5 stated, The Lasix just came from the pharmacy yesterday. The medications were confirmed as expired.

An observation and interview on 02/06/25 at 11:30 AM of the 4th station, East cart revealed the following:

Insulin Lispro 100 Unit/ml opened 12/27/24 and expired 01/17/25. Lispro 100 Unit/ml opened, but no open date and no expiration date on bottle. Insulin Glargine-YFGN U100 opened, but no open date and no expiration date on bottle x 3. Insulin Lispro 100 Unit/ml opened on 01/03/25 and expired 01/31/25. Insulin Lispro 100 Unit/ml opened 01/01/25 and expired 01/29/25. Alendronate Sodium 70 mg tablet, was belonging to an individual resident was stored with stock medication. Kerendia 10 mg tablets, belonging to an individual resident was stored with stock medication. Baclofen 10 mg tablets, belonging to an individual resident, was stored with stock medication. Acidophilus Probiotic was stored in med cart and not refrigerated after opening, as instructed on medication bottle. Amoxicillin 500 mg capsules expired on 01/02/25. Geri-Lanta regular strength antacid and antigas liquid, 12 fluid ounces, expired 07/24. Metronidazole 250 mg, individual pill noted with the stock medication in the cart. Fish Oil 1000 mg softgels, stock medication expired 01/25. Licensed Practical Nurse (LPN)1 confirmed the medications as expired.

During an interview with LPN1, on 02/06/25 at 12:07 PM, regarding the 4th station, East medication cart revealed, We refill the insulins in the refrigerator. I understand why they are expired. They run out so fast. I look at them when I think about it. Normally, I placed home meds in the slot in the area with their meds.

During an interview on 02/06/25 at 12:10 PM with LPN2 revealed, We put them in the cart, meds brought in from home. They are usually medications that are rare that we do not keep in stock. We have Baclofen, so I don't understand why those medicines were in the cart.

During an observation on 02/06/25 at 12:45 PM of 200 hall Medication cart revealed the following,

Mirtazapine 15 mg tablets, expired 01/02/25 with 25 pills left in a 30 pill card. Ropinirole 1 mg tablets expired 01/02/25 with 29 pills left in a 30 pill card. Levothyroxine 25 mg tablets expired 01/02/25 with 2 pills left in a 30 pill card.

On 02/06/25 at 01:15 PM, Registered Nurse (RN)3 verified the expiration dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 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 0761 During an observation on 02/06/25 at 01:17 PM of the 100 hall medication cart revealed the following,

Level of Harm - Minimal harm or Potassium CL ER 20 MEQ tablets expired on 01/02/25 with 8 pills left in a 30 pill card. potential for actual harm Promethazine 25 mg tablets expired on 01/31/25, with 20 pills left in a 30 pill card. Residents Affected - Many Brilinta 90 mg tablets expired on 01/02/25 , with 11 pills left in a 28 pill card.

Potassium CL ER 20 MEQ tablets expired on 01/02/25, with 24 pills left in a 30 pill card.

Pantoprazole Sod DR 40 mg tablets expired on 01/02/25 with 25 pills left out of a 30 pill card.

Vitamin D-3 10 mcg (400 IU) 100 film-coated tablets ,expired 11/24.

Geri Care Gas Relief Simethicone 80 mg chewable tablets, 100 tablets expired 09/24.

Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg inhalation solution, 2 packs of 5 vials each expired

on 08/24.

Calcium 600 dietary supplements, 60 tablets expired 01/25.

On 02/06/25 at 01:30 PM, RN2 verified the expiration dates.

During an observation on 02/07/25 at 03:46 PM of 4th Station, [NAME] Cart revealed the following,

Procure Allergy Relief Loratadine Antihistamine 10 mg, 300 tablets expired 10/24.

Buspirone HCL 7.5 mg tablets expired on 01/31/25, with 7 tablets out of a 51 tablets left on card.

Eliquis 5 mg tablets expired on 01/02/25, with 20 tablets left out of a 28 tablet card.

Dynarex Suction Tubing, expired on 08/28/24.

During an interview on 02/07/25 at 03:46 PM, LPN2 revealed, Nurses should check expiration dates before pulling the medication out of the medication cart and again before punching the medication out of the medication card and again before returning the medication card to the medication cart. If the medication is expired, it should be pulled from the cart and the pharmacy should be notified.

During an interview on 02/11/25 at 09:50 AM with the Director of Nursing (DON), she revealed there was a problem with the pharmacy. The DON stated, We received the medications after the expiration date noted on

the medication cards. We had discussions with the pharmacy. The pharmacy can prove this if need be. My expectation is that the medications are given per the seven rights of medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 52180

Residents Affected - Many Based on interviews and record review, the facility failed to employ a certified dietary manager.

Findings include:

Review of the facility policy titled Dietary Services - Staffing Policy, with an approval date of 11/21/22, documented, Policy Explanation and Compliance Guidelines for Staffing: 3. If a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition services who: a. For designations prior to Nov. 28, 2016, meets the requirements not later than 5yrs after Nov, 28, 2016 or no later than one year after Nov. 28, 2016 for designations after Nov. 28, 2016 is: i. A certified dietary manager. ii. A certified food service manager. iii. Has similar national certification for food service management and safety from a national certifying body; or .

Review of an Order Confirmation-Invoice/Receipt dated 04/19/24, revealed the acting Certified Dietary Manager is enrolled in a course from the University of North Dakota for Pathway III(b) - Dietary Manager Training.

During an interview on 02/07/25 at 9:50 AM, the Registered Dietician (RD) stated, that she is aware that the current certified dietary manager is not certified and has voiced concerns regarding food safety. The RD further stated, that she only works part-time, 8 hours per week and is not involved in the day-to-day operations. The RD concluded that she has offered the facility a contract interim travel CDM to provide coverage until the acting CDM becomes certified.

During an interview on 02/11/25 at 10:15 AM, the acting Certified Dietary Manager (CDM) stated, I am currently enrolled in an online program and will be a Certified Dietary Manager by no later than April 2025, but I hope to complete the program earlier by March 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52180 safety Based on review of facility policy, observation, interviews, and record review, the facility failed to (1) properly Residents Affected - Many store food in 1 of 1 kitchen. Additionally, the facility failed to (2) ensure proper sanitization in the three compartment sink and the dishwasher in 1 of 1 kitchen.

On [DATE REDACTED] at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.

On [DATE REDACTED] at 5:44 PM, the Administrator and Director of Nursing were notified that the failure to use sanitizer

in the three compartment sink and dishwasher constituted Immediate Jeopardy (IJ) at

F-F812 at a lower scope and severity of F.

Findings include:

(1) Review of the facility policy titled Food, Dry Storage of, with a reviewed date of ,d+[DATE REDACTED], documented,

It is the policy of the facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention, food appearance, and food quality. Procedures: . 5. All food storage bins or containers shall be maintained in clean condition and labeled with the contents.

Review of the facility policy titled Food Receiving and Storage with revised date of ,d+[DATE REDACTED], documented, Policy Interpretation and Implementation: . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated . 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day .

During an interview on [DATE REDACTED] at 9:50 AM, the Dietician stated that she works part-time 8 hours per week and has more of a clinical based role and is not involved in the day-to-day operations. The Dietician concluded that she was not aware that the kitchen staff was not using sanitizer in the three compartment sink or for dishwasher use.

During the initial tour of the kitchen on [DATE REDACTED] at 9:00 AM, revealed the following:

Dry storage:

2 - 6 pounds (lbs) cases of corn stored on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 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 0812 1 - 9 oz can not label and was also dented.

Level of Harm - Immediate 1 - 3 lbs 2 oz Campbell's vegetable soup can was dented. jeopardy to resident health or safety 2 cases of [NAME] choice corn stored on the floor. (one case with 6 cans & 1 case with 5 cans)

Residents Affected - Many 2 packs of hoagie/sub rolls not dated or labeled.

1 pack of Wonder dinner rolls expired on [DATE REDACTED].

Freezer:

1 box containing eight different unidentified food items.

2 bags of unidentified food not labeled and not dated.

1 bag of tater tots not tabled and not dated.

3 bags of an unknown food, wrapped in cellophane not labeled and not dated.

1 bag of breadsticks not labeled and not dated.

Refrigerator:

1 case of sweet potatoes not labeled or dated and the surface of the sweet potatoes had a white fuzzy substance.

1 bag of diced onions not labeled and not dated.

1 pack of sharp cheddar cheese not dated.

1 honey ham not labeled or dated.

On [DATE REDACTED] at 9:45 AM, the acting Certified Dietary Manager (CDM) confirmed these items and removed them from storage.

Review of the Temperature Logs for the refrigerator and freezer for the month of [DATE REDACTED], revealed missing temperatures on [DATE REDACTED] and [DATE REDACTED] - [DATE REDACTED]. Further review of the Temperature Logs revealed the log had not been started for the month of February 2025.

(2) Review of the undated facility policy titled Dishwashing: Machine Operation, documented, Procedure: 1. All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized . or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 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 0812 Review of the facility policy titled Dishwashing: Manual, documented, All pots and pans shall be cleaned by washing, rinsing, and sanitizing . 4. The pots and pans will be . sanitized by either heat or chemicals in the Level of Harm - Immediate third compartment. jeopardy to resident health or safety Review of the undated Manufacturer Label titled, NSF Operational Requirements as Manufactured by CMA Dishmachines revealed the following: Wash Temp. - Minimum 120 degrees Fahrenheit, Recommended 140 Residents Affected - Many degrees Fahrenheit ., Rinse Temp. - Minimum 120 degrees Fahrenheit, Recommended 140 degrees Fahrenheit, Required - 50 PPM Available Chlorine.

During an observation and interview on [DATE REDACTED] at approximately 1:00 PM, Kitchen Crew (KC)1 was utilizing

the dishwasher to wash dishes. Cook1 proceeded to test the sanitization level of the dishwasher. Cook1 pulled a test strip and dipped it in the overflow of the dishwasher. The test strip did not give a reading of the sanitization level. Cook1 proceeded to check it again and received the same results. Cook1 and Kitchen Manager (KM)1 (who came from a sister property to assist) began troubleshooting and determined that the dishwasher was not receiving sanitizer. On the floor next to the dishwasher were three buckets that provided chemicals to the dishwasher. One bucket contained liquid dish machine detergent, one bucket contained liquid [NAME] metal safe dish machine detergent and the other bucket contained [NAME] Dri rinse aid. Neither of the buckets contained sanitizer. Additionally, observation of the temperature gauge on the exterior of the dishwasher revealed the temperature of the dishwasher, after multiple cycles, was 94 degrees Fahrenheit. KM1 stated there was no dishwasher sanitizer in the building and she would borrow one from her home facility. Further observation revealed the lunch meal was on the steam table and kitchen staff preparing to plate food on regular plates.

During an observation on [DATE REDACTED] at approximately 1:15 PM, revealed the wash compartment of the three compartment sink was full of water with the top of a metal pot sticking out the top of the water. The rinse compartment and the sanitizing compartment were both empty. The three compartment sink was set up with

an automatic dispenser which dispensed Array Ultimate Sanitizer and Array [NAME] Pot and Pan Detergent connected to the appropriate compartments.

During an interview [DATE REDACTED] at 1:30 PM, Cook1 stated she usually uses all three compartments when she washes dishes, but rarely washes dishes. Cook1 further stated, that some staff use all three compartments and some don't. Cook1 concluded that the rinse compartment of the three compartment sink is stopped up.

During an interview on [DATE REDACTED] at 1:35 PM, Kitchen Crew (KC)2 stated, she has worked at the facility for 7 months and has never seen anyone use that side of the sink (sanitizer compartment).

During an interview on [DATE REDACTED] at approximately 1:35 PM, KM1 revealed the dishwasher broke on [DATE REDACTED] and was fixed on [DATE REDACTED]. KM1 revealed the kitchen was using Styrofoam containers when the dishwasher was down, but was still using regular cups to serve the residents. KM1 further stated the cups were being washed in the three compartment sink. The kitchen switched from Styrofoam containers to regular plates on [DATE REDACTED]. KM1 verified the concerns with the temperature and sanitization of the dishwasher and the sanitization in the three compartment sink. After KM1 verified these concerns, direction was given to staff to switch back to Styrofoam containers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 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 0812 During multiple interviews with staff, to include Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants, on [DATE REDACTED] from 4:19 PM to 4:27 PM, all confirmed the use of heated plates during lunch Level of Harm - Immediate and dinner service on [DATE REDACTED]. jeopardy to resident health or safety The facility's removal plan included the following:

Residents Affected - Many 1. Corrective action for residents found to have been affected by this deficiency::

Sanitizer for dishwasher and 3-compartment sink was properly installed by Dietary Resource.

All dishes, pots, pans, and utensils were washed and sanitized due to the alleged deficient practice by dietary staff after education was provided by Dietary Resource.

Every shift monitoring for three days for signs and symptoms of foodborne illness due to potential cross-contamination was placed on all residents who take food and/or drink by mouth was entered by Unit Manager and Clinical Resource.

2. Corrective action for residents that may be affected by the deficiency:

The Medical Director was notified of the IJ on [DATE REDACTED] at 6:34 PM.

All residents who take food and/or drink by mouth have the potential to be affected by the deficient practice.

Sanitizer for dishwasher and 3-compartment sink was properly installed by Dietary Resource.

All dishes, pots, pans, and utensils were washed and sanitized due to the alleged deficient practice by dietary staff after education was provided by Dietary Resource.

Every shift monitoring for three days for signs and symptoms of foodborne illness due to potential cross-contamination was placed on all residents who take food and/or drink by mouth was entered by Unit Manager and Clinical Resource.

3. Other Plan of Removal actions:

All dietary staff currently working were educated on [DATE REDACTED] by Dietary Resource on proper use of sanitizer for dishwasher and 3-compartment sink.

All dietary staff will receive education on proper use of sanitizer for dishwasher and 3-compartment sink prior to the start of their next shift.

Education will be included as part of the annual skills fair and new hire orientation for all kitchen staff.

An adhoc QAPI meeting regarding the items in the IJ template completed on [DATE REDACTED]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 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 0812 Daily audit of sanitizer detergent for proper hook up and function to dishwasher and 3-compartment sink x12 weeks and monitored by Dietary Manager or Designee. Level of Harm - Immediate jeopardy to resident health or Daily audit of dishwasher to ensure the machine is functioning at manufacturer recommendations and safety specifications to included temperature monitoring. Audit will be completed x12 weeks.

Residents Affected - Many Dietary Manager or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.

Date of Compliance: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 37781 potential for actual harm Based on review of the facility documentation and interviews, the facility failed to employ a qualified, full-time Residents Affected - Many Social Worker as required by regulation.

Findings include:

Review of the facility's Social Services Staff-Job Description indicated, Essential Duties and Responsiblities: Assist in the development, administering, and coordinating of department policies and procedures, Participate in discharge planning, development and implementation of social care plans and resident assessments .

During an interview on 02/04/25 at 1:38 PM, the Social Worker Interim/Designee (SWI), confirmed that she does not have a license, or social worker certification. She has been working in the position of Social Services Designee for approximately 1 month. She is also currently the Central Supply Coordinator. The SWI indicated she held the position as Social Worker Designee last year with the following dates: February through October 2024 and November through December 2024. The SWI stated, the full time SW was let go.

During the Resident Council Meeting on 02/05/25 at 10:00 AM with the surveyors, multiple residents conveyed the facility did not have a Licensed Social Worker and has not for a period of time.

During an interview with the Administrator on 02/04/25 at approximately 3:15 PM, he confirmed the facility does not have a Social Worker currently in the facility. Administrator reported facility is in the process of hiring a fulltime SW, but there is none presently.

During an interview with Unit Manager (UM)4 on 02/05/25 at 9:38 AM, she stated, She is here for guidance so the SWI. She confirmed she does not have a SW Degree. UM4 stated she has been working with SWI off and on because there have been two (2) social workers in between time, from last year to this year, but she is not familiar with many SW duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49918 potential for actual harm Based on review of the facility policy, observations, and interviews, the facility failed to ensure staff were Residents Affected - Few using appropriate personal protective equipment (PPE) with residents on Enhanced Barrier Precautions (EBP) 1 of 1 resident, (R)76.

Findings include:

Review of the facility's policy titled, Enhanced Barrier Precautions, copyright 2022, revealed, It is the policy of

this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.

3. Implementation of Enhanced Barrier Precautions

A. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray.

7. Enhanced barrier precautions should be used for the duration of the affected residents stay in the facility or until the wound heals or indwelling medical device is removed.

Review of Resident R76's Face Sheet revealed Resident R76 was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, gastrostomy status, protein-calorie malnutrition, and personal history of traumatic brain injury.

Review of Resident R76's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25 revealed Resident R76 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed.

Review of Resident R76's Care Plan with a start date of 07/19/2024 documented, Resident R76 receives peg tube feeding related to diagnosis of adult failure to thrive due to having multiple cerebrovascular accidents (CVA), history of total brain injury (TBI), dysphagia. He is receiving all nutrition and hydration via peg tube but has been working with speech therapy. Further review of the Care Plan revealed the following approach, Change 60 cc syringe and feeding tube every 24 hours, check residuals, check tube placement/patency before and after giving medications and starting feedings, enhanced barrier precautions: PPE required for high resident contact care activities. Indication: Peg Tube, flush tube with 10 cc water in between each medication administration, head of bed (HOB) elevated 45 degrees at all times during feeding.

Review of Resident R76's Physician Orders dated 08/16/2024 revealed the following Enteral Feed Order every night shift change 60 cc syringe and feeding tube every 24 hours.

Review of Resident R76's Physician Orders dated 08/16/2024 revealed the following Enteral Feed Order every shift check residuals and hold tube feeding if residuals above 100 ccs, resume after 2-hour period; every shift check tube placement/patency before and after giving medications and starting feedings; every shift flush tube with 10cc water between each medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 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 0880 Review of Resident R76's Physician Orders dated 09/30/2024 revealed the following Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: PEG Tube every shift for wound. Level of Harm - Minimal harm or potential for actual harm Review of Resident R76's Progress Note dated 01/08/25 revealed Enteral Feed Order, two times a day Isosource 1.5 @ 65 cc/hr with 50cc/hour water flush x 20 hours (provide 1950 kcal, 83g protein, 1988 water) Off at 8AM on Residents Affected - Few at 12 PM no longer needed.

During an observation on 02/07/25 at 10:21 AM, Certified Nursing Assistant (CNA)7 and CNA8 were observed to be walking in Resident R76's room, preparing to do Activities of Daily Living (ADLs) care.

During an interview on 02/07/25 at 10:34 AM, Registered Nurse (RN)3 stated, The Assistant Director of Nursing (ADON) or DON writes up in-services and present education, as needed. We do yearly education on Relias. The education requirements are due in October. When we educate specific education, we give in-services to improve performances as needed. We monitor the staff after in services to ensure competencies. We do have skill fairs, and we do building wide education once we see education is needed.

During an observation on 02/10/25 at 11:08 AM, CNA7 and CNA8 entered Resident R76's room to do morning ADLs. Outside of Resident R76's room door, an empty PPE bin was observed. The CNAs did not don PPE prior to completing the morning bath for Resident R76, who has a PEG tube.

During an interview on 02/10/25 at 11:12 AM, CNA8 stated, I am sorry, I forgot to put on my PPE.

During an interview on 02/10/25 at 11:14 AM, Licensed Practical Nurse (LPN)4 stated, Every time we get a new admission, we go over education on barrier precaution. We do a skills fair yearly.

During an observation on 02/10/25 at 01:18 PM, CNA7 was observed coming out of room [ROOM NUMBER]D. She had just assisted with Resident R76's ADLs.

During an interview on 02/10/25 at 01:20 PM, CNA7 stated, I keep forgetting to put on the PPE. I am sorry.

During an interview on 02/10/25 at 1:30 PM, the Director of Nursing (DON) stated, My expectations of my management staff and myself is to observe the staff on the floor using proper PPE. We go over infection control protocols in our staff meeting. We educate staff on compliance and we have our yearly skills fair. We discuss the purpose and dominant infections and why we do the process of donning and doffing. We provide

a hands-on skills fair to teach prevention of infections amongst other skills.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 49800

Residents Affected - Few Based on review of the facility policy, observations, and staff interviews, the facility failed to provide and maintain a safe, sanitary environment in the Unit 4 shower room/toilet area.

Findings include:

Review of the facility's policy titled, Environmental Conditions /Environmental Rounds, revised on 11/2019, indicated It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds.

Review of the facility's policy titled, Facility Maintenance, revised on 05/2007, indicated It is the policy to establish procedures for routine and non-routine care of the facility /building to ensure that the facility remains in good working order for resident and staff safety.

During an observation of the Unit 4 shower room/toilet area on 02/05/25 at 10:15 AM, the following concerns were noted:

a. Inside of the toilet bowl, located in the Unit 4 shower room/toilet area was stained with a dark, greenish dried substance splattering from the rim down into bowl. There was no water present in the toilet bowl and a foul odor was noted. The shower room appeared dark with poor lighting.

b. There was white toilet tank lid placed over the soiled toilet bowl.

During an observation on 02/06/25 at 1:12 PM, feces remained in the toilet and the tank lid over the toilet bowl. The shower room continues to be dark, with poor lighting.

During an observation on Unit 2 on 02/06/25 at approximately 2:02 PM, the Maintenance Assistant was pushing a soiled toilet on a cart, down the hallway.

During an observation of the Unit 4 shower/toilet area on 02/06/25 at approximately 3:10 PM, there was a newer, clean toilet with no dark, greenish dried substance splattering from rim down into bowl. There were no foul odors noted, however, the lighting remains dim.

During an interview on 02/06/25 at 10:06 AM, Housekeeper (HK)1, reported she is responsible for cleaning Unit 4, rooms 719-732, nursing station, and bathroom near the nursing station. HK1 stated, I have never cleaned the shower/bathroom and she does not have code to get into shower/bathroom. HK1 stated, they have not given her the code to shower. HK1 stated she has observed staff taking residents in and out of the shower/toilet area for showers and no one has ever asked for the shower/toilet area to be cleaned.

During an interview on 02/06/25 at approximately 10:10 AM, Licensed Practical Nurse (LPN)1 stated, The shower is used for resident showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 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 0921 During an interview on 02/06/25 at 10:15 AM, the Housekeeping Supervisor, (HKS), stated, If the facility showers are working, housekeepers are responsible for sweeping, mopping the floors, sanitizing, cleaning Level of Harm - Minimal harm or toilets, changing paper towels and trash liners. After the HKS observed the Unit 4 shower /toilet area, HKS potential for actual harm reported he was unaware of the feces in the toilet. HKS confirmed the lighting was dim in the shower/bathroom area. HKS stated, He was unaware of HK1 not having the code to get into and having Residents Affected - Few access to shower/bathroom area. HKS stated, He would contact maintenance, and once the toilet is working,

he would have the housekeeper clean the shower, including the toilet. HS reported he has check list for monthly deep cleans for resident rooms, but does not have checklist for everyday cleaning for the housekeepers. HKS reported he would implement a checklist for daily cleaning, as well for housekeepers.

An observation was conducted on 02/06/25 at approximately 1:00 PM, with the Maintenance Supervisor (MS) in the Unit 4 toilet/shower room, along with the HKS. After the MS observed the 400 shower/toilet area,

he stated, It was disgusting, and would replace as soon as possible. The MS indicated he was unaware that

the Unit 4 shower area, toilet was inoperable. MS reported the procedure for reporting broken equipment is for staff to complete and submit a maintenance request form to the Maintenance Department. The MS reported he had not received a maintenance request for the broken toilet or the poor lighting. The MS stated, Lights would be changed to LED lighting, probably next week to increase lighting in shower/toilet area.

During a follow-up interview with the MS on 02/07/25 at approximately 9:10 AM, he stated, The broken toilet was replaced with a new toilet on yesterday. MS reported he replaced the flapper, toilet handle, toilet floater and toilet wax ring.

During a follow-up interview with the HKS on 02/07/25 at approximately 9:19 AM, HKS indicated HK1 was given the code again on yesterday. HKS reported codes to all shower/areas with keypads are given upon hire. HKS reported HK1 switched halls with another housekeeper, however she should have known the code to get into Unit 4 shower/toilet area, to clean it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 425121