Pruitthealth- Dillon

F-F605 include: Resident R369 was admitted to the facility on [DATE REDACTED] with a diagnosis including but not limited to unspecified dementia without behaviors, major depressive disorder, anxiety disorder, and adjustment disorder. Resident R369 displayed exit seeking behaviors upon admission and throughout her stay within the facility. Interventions of 1:1 supervision and placement of an Electronic Monitoring Device (EMD) were put into place to ensure resident safety and security. While Resident R369 was in the facility, partners/staff attempted to redirect the resident when she displayed exit seeking behaviors and she stated, I am going home with family . He knows not to leave me here. Medical Director (MD)1 witnessed Resident R369 displaying exit seeking behaviors and that the partners/staff were having difficulty redirecting the resident due to the resident's agitation. MD1 placed a one-time order of Haloperidol 5 mg oral tablet for the resident's agitation. Methods to identify any other resident who might be affected include: all ambulatory residents with exit seeking behaviors and increased agitation. Systemic Changes include: the facility regional Area [NAME] President (AVP) and or Senior Nurse Consultant (SNC) has scheduled an in-service on 06/20/24 to be instructed by our Chief Medical Officer to the facility MD (MD1). This in-service will include recommendations of interventions for residents with increased agitation while displaying exit seeking behaviors that are following the manufacturer's recommendations of the medication while meeting the Center's of Medicare and Medicaid (CMS) regulations/guidelines for not chemically sedating. New orders for psychotropic will be reviewed with the MD and Quality Assurance and Performance Improvement (QAPI) committee monthly to ensure/confirm rational and appropriate usage. The date of substantial compliance is set at 06/21/24. Monitoring includes: the Administrator will present results of reviews to the QAPI Committee monthly for three months and or until substantial compliance is achieved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42424

Residents Affected - Few Based on interview, record review, and review of facility policy, the facility failed to implement care plan interventions for Resident (R)55 for oxygen use, for 1 of 3 residents reviewed for care plans.

Findings include:

Review of the facility policy titled Care Plans last revised on 07/21/21, revealed, It is policy of the health care center for each patient/residents to have a person centered baseline care plan followed by a comprehensive care plan developed following the completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Comprehensive care plans should be reviewed not less than quarterly according to the MDS schedule, following the completion of the assessment. Care plans updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by Nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.

Review of Resident R55's Face Sheet revealed Resident R55 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: respiratory syncytial pneumonia, sleep apnea, type 2 diabetes, and muscle weakness.

Review of Resident R55's Quarterly MDS with an Assessment Reference Date (ARD) of 06/05/24, revealed Resident R55 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates that Resident R55 is cognitively intact. Further review of the Quarterly MDS revealed that Resident R55 utilizes oxygen as a special treatment.

Review of Resident R55's Physician Order Report dated 05/21/24 - 06/21/24, revealed Resident R55 had an order for oxygen with a start date of 05/16/24, at 2 liters/minute via nasal cannula as needed.

Review of Resident R55's Care Plan revealed Resident R55 no care plan or interventions related to oxygen or oxygen usage.

During an interview on 06/18/24 at 11:30 AM, Resident R55 revealed they were unsure of the last time the facility spoke with her about her plan of care/care plan meetings.

During an interview on 06/21/24 at 10:36 AM, Licensed Practical Nurse (LPN)4 verified that Resident R55 had not been care planned and has no intervention for oxygen use in her Electronic Medical Record (EMR) at this time. LPN4 stated that according to the EMR, Resident R55's last care plan conference occurred on 03/04/24 and a quarterly care plan should have taken place on 06/02/24, but was unable to verify that it occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 0657 During an interview on 06/21/24 at 11:24 AM, the Director of Nursing (DON) revealed Resident R55 should have a care plan and interventions related to her oxygen use and they were also not able to verify if a care plan Level of Harm - Minimal harm or meeting took place on 06/02/24 for Resident R55 and their resident representative. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 47075 potential for actual harm Based on review of facility policy, observation, interview, and record review, the facility failed to ensure a Residents Affected - Few resident who was dependent on staff for Activities of Daily Living (ADLs) received the necessary services to maintain personal hygiene, specifically nail care, bed baths and showers, for 1 of 7 sampled residents (Resident (R) 2).

Findings include:

Review of the facility policy titled, Charting Activities of Daily Living (ADLs) with a date of 2014, revealed, Definitions: Activities of Daily Living (ADLS's): The task of everyday life. The ability or inability to perform ADL's is a measurement of the functional status of a person.

Review of Resident R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/24, indicated Resident R2 was admitted to the facility from the hospital on 03/17/23, with diagnoses including but not limited to: chronic obstructive pulmonary disease with (acute) exacerbation, chronic diastolic (congestive) heart failure, malignant neoplasm of upper lobe, left bronchus or lung, syndrome of inappropriate secretion of antidiuretic hormone, and dementia. Further review of the MDS revealed Resident R2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which revealed the resident was moderately cognitively impaired.

During an observation on 06/18/24 at 2:04 PM, Resident R2 was lying in bed, hair disheveled, nails dirty, face and clothing had dried on food.

During an observation on 06/19/24 at 11:20 AM, Resident R2's hair was unkept, she was wearing a black shirt with a bright pink emblem. Resident R2's nails were dirty. Resident R2's face, clothing, and sheets contained dried food.

During an observation on 06/20/24 at 11:03 AM, Resident R2 was lying in bed with the same black and pink shirt that

she wore on the previous day. Resident R2's nails were dirty, hair unkept, and dried food was on her clothes, face, and sheets.

During an observation on 06/20/24 at 4:34 PM, Resident R2 was lying in bed with the same black and pink shirt that

she wore previously. Resident R2's nails were dirty, hair unkept, and dried food was on her clothes, face, and sheets.

During an interview on 06/20/24 at approximately 7:03 PM, Certified Nursing Assistant (CNA)4 revealed she was not assigned to Resident R2. CNA4 stated, It is never acceptable for residents not to get assistance daily with ADL care.

During an interview on 06/20/24 at approximately 7:18 PM, CNA1 revealed she was assigned to Resident R2 and is familiar with the resident. CNA1 stated Resident R2 requires extensive care and follows Resident R2's shower schedules that are in the system. Resident R2 gets bed baths on the days that she does not get showers. CNA1 further stated nail care and hair care is included when she provides ADL care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47075

Residents Affected - Many Based on review of facility policy, observation, interview, and record review, the facility failed to ensure: accurate labeling and dating of foods and removal of expired foods from 1 of 1 main kitchen.

Findings include:

Review of the facility policy title Labeling, Dating, and Storage dated 2014, revealed, Policy Statement: It is

the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety.

During an observation on [DATE REDACTED] at 10:47 AM, with the Dietary Manager (DM), revealed the cooler contained

the following:

2 rotten heads of cabbage, dated [DATE REDACTED],

3 cucumbers undated in a box that contained potatoes,

1 jar of reliance Italian dressing, opened [DATE REDACTED] with an expiration date of [DATE REDACTED],

1 large container of Apple Sauce dated [DATE REDACTED], no expiration date.

During an interview on [DATE REDACTED] at 12:48 PM, the Kitchen Manager-Dietary Manager (DM) revealed labeling, storing, discarding of expired items are done by all staff and all staff received training. The items are always first in first out in all storage areas. It is the DM's expectation that staff always label, date, and discard of expired items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42424

Residents Affected - Few Based on interview, record review, and review of facility policy, the facility failed to maintain complete and accurate medical records for Resident (R)55, in accordance with accepted professional standards and practices, for 1 of 5 residents reviewed.

Findings include:

Review of the facility policy titled Maintenance of Medical Records last revised on 12/06/22 revealed, It is the policy of the facility to maintain a medical record for each patient/resident in the healthcare center/agency that is to be accurate, complete, and systematically organized.

Review of Resident R55's Face Sheet revealed Resident R55 was admitted to the facility on [DATE REDACTED], with the diagnoses including but not limited to: respiratory syncytial pneumonia, sleep apnea, type 2 diabetes, and muscle weakness.

Review of Resident R55's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/05/24, revealed Resident R55 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that she is cognitively intact. Further review of the Quarterly MDS revealed that Resident R55 utilizes oxygen as a special treatment.

Review of Resident R55's Physician Order Report dated 05/21/24 - 06/21/24, revealed Resident R55 had an order for oxygen with a start date of 05/16/24 at 2 liters/minute via nasal cannula as needed.

Review of Resident R55's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2024, revealed that Resident R55 has an order for O2 (oxygen) at 2 Liters per min via nasal cannula as needed. Further review of the MAR and TAR revealed nursing staff did not document times oxygen were administered, reason for administering, and follow result from being administered from 06/01/24 - 06/20/24.

Review of Resident R55's MAR and TAR for May 2024, revealed Resident R55 had an order for oxygen at two liters a minute via nasal cannula as needed. Further review of the MAR and TAR revealed nursing staff did not document times oxygen were administered, reason for administering, and follow results from being administered from 05/16/24 - 5/31/24.

Review of Resident R55's Nursing Notes revealed several different nursing staff incorrectly charting the oxygen that was administered to Resident R55 as 3 liters/minute instead of the Physician Ordered 2 liters/minute, on the following dates: 05/05/24, 05/06/24, 05/08/24, 05/27/24, and 06/02/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 0842 During an interview on 06/21/24 at 10:36 AM, Licensed Practical Nurse (LPN)4 revealed that the resident is

on PRN (as needed) oxygen use, nursing staff don't always document in the MAR when a resident is on Level of Harm - Minimal harm or PRN oxygen use, only for continuous usage. LPN4 further stated that Resident R55 will take off her oxygen potential for actual harm throughout the day at times and will mostly use her oxygen while laying in bed, she discontinues when attending therapy. LPN4 reviewed Resident R55's Physician Orders and verified that oxygen is at 2 liters. LPN4 Residents Affected - Few reviewed Resident R55's nursing notes and verified that nursing documentation has been incorrectly charted at 3 liters by several nursing staff.

During an interview on 06/21/24 at 11:24 AM, the Director of Nursing (DON) expects nursing staff to document in the MAR when a resident is on oxygen even if the order is as needed/prn. The DON also stated that her expectation is for nursing staff to document accurately in the EMR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 425113 Department of Health & Human Services Printed: 09/23/2025 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 425113 B. Wing 06/21/2024

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

Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536

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 47075 potential for actual harm Based on review of the facility policy, observations, interviews, recorded reviews, the facility failed to utilize Residents Affected - Few appropriate hand hygiene during serving of meals on 1 of 3 units.

Findings include:

Review of the facility policy titled Infection Prevention - Hand Hygiene dated 2014, revealed, D. Indication Requiring Hand Wash or Hand Rub: 9. Passing meal trays to residents.

During an observation on 06/19/24 at 8:18 AM, revealed on the Northside, staff not sanitizing their hands while passing out breakfast trays to residents.

During an observation on 06/19/24 at approximately 12:37 PM, Certified Nursing Assistant (CNA)3 was not sanitizing her hands while passing out lunch meal trays.

During an observation on 06/20/24 at 5:37 PM, CNA4 was not sanitizing her hands while passing out dinner meal trays.

During an interview on 06/19/24 at approximately 2:37 PM, CNA3 revealed the policy and procedure for sanitizing hands while passing out meal trays is to always sanitize hand before going in the room and coming out of the residents' room, no exceptions.

During an interview on 06/20/24 at approximately 7:03 PM, CNA4 stated, You always wash hands before passing out the trays and after wash them passing out the meal trays.

During an interview on 06/21/24 at 8:43 AM, the Director of Nursing (DON) revealed all staff are required to sanitize their hands before passing out meal trays and after passing out meal trays, any time the staff hands become soiled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 425113