Faith Healthcare Center
Faith Healthcare Center in Florence, SC — inspection on March 11, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R105's Progress Note, dated 01/28/26, located in the resident's archived paper medical record and completed by the Nurse Practitioner (NP) revealed, .the resident is seen today for follow-up evaluation to assess the need for transfer to a higher level of care due to ongoing severe behavioral disturbances and psychosis related to schizophrenia.Discussed with administrator and Hospital social services regarding the transfer above and they are aware and agreeable to assist with this issue. R105 was transferred to the hospital on this date.Further review of R105's archived paper medical record revealed there was no evidence that the resident and/or their RP was issued a written notice of transfer or a bed hold upon or soon after the resident's transfer to the hospital.
During an interview on 03/10/26 at 4:39 PM, the Administrator stated, .there was no bed-hold policy or written notice of transfer provided to the RP [of R105] .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
425009 03/11/2026
Faith Healthcare Center 617 West Marion Street Florence, SC 29501
Review of R9's Face Sheet, in the resident's paper medical revealed the resident was admitted to the facility on [DATE] with diagnoses which included pneumonia.
Review of R9's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/26, located under the Assessments section of the MDS, indicated R9 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated the resident was moderately cognitively impaired.
During an interview and observation of R9 on 03/09/26 at 10:34AM, a nebulizer machine, mask, and tubing were observed on the resident's nightstand uncovered.
The mask and tubing were not labeled or dated to indicate when they were last replaced. R9 confirmed that the nebulizer belonged to him and stated that he believed he had recently received a nebulizer treatment because he had been feeling congested.
Review of R9's Physician's order, located in the resident paper medical record under the Physician's Orders section revealed an order dated 01/05/26 of Ipratropium/Albuterol; 1 vial (3ML [milliliter]) nebulizer every six hours as needed for pneumonia. change nebulizer tubing one time a day every week on Sunday. A review of R9's Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated January 2026, February 2026, and March 2026 and located under the MAR/TAR section of the resident's paper medical record, indicated that R9 had not received a nebulizer treatment since admission.
During a follow-up observation on 03/10/26 at 10:37AM, the nebulizer, mask, and tubing remained on the R9's nightstand and continued to be stored uncovered.
During an interview on 03/10/26 at 2:24 PM, Licensed Practical Nurse (LPN) 2 confirmed that R9 had not received a nebulizer treatment per the MAR, as it would have been documented on the MAR. LPN2 further stated that the nebulizer equipment was normally stored in a bag in the resident's drawer, but that the resident had removed it.
During an interview on 03/11/26 at 10:18AM, the Director of Nursing (DON) stated that nebulizers, masks, and tubing are expected to be cleaned and stored properly.
She further stated that when mask and tubing are replaced, they should be labeled with the replacement date or documented in a log.
425009 03/11/2026
Faith Healthcare Center 617 West Marion Street Florence, SC 29501
Review of R14's Evaluation For Use of Bed Rails, dated 05/01/25 and found in the resident's paper medical record located at the nurse's station revealed no documented evidence it was recommended for the resident to have side rails on his bed.
Review of R14's complete paper medical record revealed no documented evidence of any other evaluations for the use of side rails.
During an interview on 03/10/26 at 2:03 PM, Unit Manager/Licensed Practical Nurse (UM/LPN1) confirmed the side rails were raised on R11's and R14's beds. UM/LPN1 stated residents were to have physician's orders for use of the side rails.
UM/LPN1 also stated she thought side rail evaluations for continued use of the side rails were to be done annually.
During an interview on 03/10/26 at 2:54 PM, the Director of Nursing (DON) confirmed side rail use was to be assessed quarterly.
The DON stated physician orders and a care plan were to be in place for the use of side rails.
The DON confirmed she could not locate anything to show that R11 had ever been assessed, or that informed consent was obtained for her use of side rails.
The DON also confirmed that R14 had most recently been evaluated for his use of side rails on 05/01/25 (10 months prior to the survey).
The DON stated there was not a physician's order for R14 to have side rails and that a care plan had not been developed for the resident's use of side rails.
She stated her expectation was these things should have been done.
425009 03/11/2026
Faith Healthcare Center 617 West Marion Street Florence, SC 29501
Review of R11's undated Resident Face Sheet found in the resident's paper medical record at the nurse's station, revealed the resident was admitted to the facility on [DATE] with diagnoses which included history of stroke and dementia with psychotic disturbance.Observation on 03/09/16 at 12:31 PM revealed R11 was lying in her bed with her eyes closed.
One side of the resident's bed was against the wall, and the other side of her bed had 1/3 side rails in the raised position in the middle of the bed.
Review of R11's complete paper medical record located at the nurse's station nothing to indicate the maintenance department had assessed that R11's bed was equipped with side rails that were safe and functioned properly.
Review of the facility's untitled bed maintenance documentation provided by the facility revealed no documented evidence indicate the maintenance department had assessed R11's bed was equipped with side rails that were safe and functioned properly. 2.
Review of R14's undated Resident Face Sheet found in the resident's paper medical record at the facility nurse's station, revealed the resident was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder.
Observation on 03/09/26 at 12:49 PM revealed R14 was lying in his bed with his eyes closed.
The resident had 1/3 bilateral side rails in the raised position in the middle of the bed.
Review of the resident's complete paper medical record located at the nurse's station revealed nothing to indicate the maintenance department had assessed that R11's bed was equipped with side rails that were safe and functioned properly.
Review of the facility's untitled bed maintenance documentation provided by the facility revealed no documented evidence indicate the maintenance department had assessed R11's bed was equipped with side rails that were safe and functioned properly.
During an interview on 03/10/26 at 2:03 PM, Unit Manager/Licensed Practical Nurse (UM/LPN1) stated it was the responsibility of the Maintenance Department to conduct physical assessments of any resident bed for which side rails were to be applied.
During an interview on 03/10/26 at 2:27 PM, the Maintenance Director (MD) stated general physical checks on resident beds were conducted by the facility maintenance team periodically; however, beds were not specifically checked by maintenance for each resident when rails were applied to the bed to ensure physical safety. He stated, We assume the nurses have done that.
The MD further stated that neither R11's nor R14's bed and the attached side rails had been inspected or checked for safety.
During an interview on 03/10/26 at 2:54 PM, the Director of Nursing (DON) stated that resident beds that were equipped with side rails or that would be equipped with side rails, it was her expectation that the side rails to be physically safe to keep residents becoming entrapped within the bed mattress and side rail.