Sumter East Health & Rehabilitation Center

F-F604, constituting substandard quality of care.

The findings include:

Review of the facility policy titled, Restraint Free Environment, documents, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits

the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints . Physical Restraint, refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove and restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to . Holding down a resident

in response to behavioral symptoms, during the provision of care if the resident is resistive or refusing the care.

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

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 5 425107 Department of Health & Human Services Printed: 09/04/2025 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 425107 B. Wing 03/20/2025

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

Sumter East Health & Rehabilitation Center 880 Carolina Avenue Sumter, SC 29150

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 0604 The facility admitted Resident R1 on 06/27/24 with diagnoses including but not limited to, respiratory failure with hypoxia, dependent on renal dialysis for ESRD (End Stage Renal Disease), peripheral vascular disease and Level of Harm - Immediate left and right below the knee amputations. Further review revealed, Resident R1 has a dialysis catheter to his right jeopardy to resident health or upper chest area. safety

Review of Resident R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/25, Residents Affected - Few revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident R1 was cognitively intact. Further review of the MDS revealed Resident R1 is not scored for moods and behaviors.

Review Resident R1's Care Plan revealed Resident R1 had a self care deficit related to activities of daily living (ADLs) and impaired mobility, muscle weakness, and lack of coordination, with pulmonary edema, and incontinence of bowel and bladder. Resident R1 is receiving oxygen therapy related to acute and chronic congestive heart failure, restrictive lung disease and cardiomyopathy.

During an interview on 03/17/25 at 11:58 AM, the Social Services Director (SSD) stated that Resident R1 told her that CNA1 was rough with him and overly aggressive. The SSD stated that Resident R1 has bilateral amputations and when he lays back his stumps will raise up a little. The SSD stated CNA1 grabbed both of the resident's hands, held them in one of his hands and pressed them against Resident R1's upper chest and neck area. The SSD further stated that CNA1 told the resident, You are not going to hit me. The SSD stated that CNA1 held down Resident R1's hands while he performed incontinent care for Resident R1. The SSD concluded that Resident R1 became distressed, was very upset and felt abused by the act.

During an interview on 03/17/25 at 12:18 PM, the Director of Nursing (DON) stated, [CNA1] is arrogant and out spoken and is in the military Reserves. CNA1 had informed the DON that he grabbed both of the resident's hands and with one of his hands, he held them down across Resident R1's upper chest and neck area. CNA1 said to the DON, I had no choice but to restrain him.

During an interview on 03/17/25 at 2:25 PM, CNA1 stated, The resident put on his call light, as he does several times during the night and was whining. I was not assigned to the resident, his CNA was busy taking care of another resident. I went in to see if I could help him. I was turning him over to loosen his brief and he swung at me and hit me. I tried blocking his hand with my hands and he stopped for a minute and I continued changing him and left the room. CNA1 did not mention restraining Resident R1 by holding his hands pressed against his upper chest.

Review on 03/17/25 at 2:35 PM, of the statement written by CNA1 revealed, Resident put on his call light, I, myself went in and asked what was wrong and he said he needed a brief change. So, I told him the CNA working with him would be with him and he said ok. I left the room to finish my rounds, and the resident started to whine. His CNA for the night was falling behind so I went in his room and told him I was going to change him and he swung at me so I restrained him until he cooled down. He let me change him and I left

the room. He threatened me and disrespected me physically and vocally.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 425107 Department of Health & Human Services Printed: 09/04/2025 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 425107 B. Wing 03/20/2025

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

Sumter East Health & Rehabilitation Center 880 Carolina Avenue Sumter, SC 29150

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 0604 During an interview on 03/17/25 at 3:28 PM, Resident R1 stated, The CNA came in my room when I rang the call bell,

he just started hitting my stumps. My left stump is still tender because it has not been long since I had the Level of Harm - Immediate amputation. The CNA went out of the room so I called again. He came back in and grabbed me and held my jeopardy to resident health or hands down around the upper part of my chest. I was scared he would pull out my dialysis catheter, so I just safety quit struggling with him. In a little while he quit holding me down. I never hit him or pushed him. I could not believe he was doing me like that. My CNA, a female, that usually helped me was helping someone else at Residents Affected - Few the time. That is why he came in my room in the first place.

During an interview on 03/20/25 at 10:40 AM, Licensed Practical Nurse (LPN)1 states, she was the nurse coming on duty for the day shift on 03/02/25. Resident R1 started calling for this nurse as soon as he saw she was there. LPN1 stated that Resident R1 was very upset and it took a few minutes to calm him down. LPN1 stated that Resident R1 was not crying, but he was very upset. LPN1 stated she informed him that he was safe and that the CNA would not be back and could not hurt him. After he appeared calmer, LPN1 left the room for a few minutes to go and report what the resident had said. The resident was adamant about calling his family and wanting to press charges against the CNA.

On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan, which included the following:

Please accept this as our plan for abatement of the Immediate Jeopardy with a date of compliance of 03/20/25.

Actions taken for the affected resident:

On 03/02/2025 at approximately 07:15 AM, Resident #1 reported to the Licensed Practical Nurse #1 (LPN1)

the he (Resident R1) wanted to call the police to press charges against CNA #1. The resident then went on to disclose how CNA#1 was rough with him and smacked his leg. LPN1 informed the Unit Manager and the Director of Nursing.

On 03/02/2025 at approximately 07:30 AM, the Director of Nursing (DON) was contacted by LPN1 and was notified of the allegation. LPN1 remained with the resident pending the arrival of the DON to start the investigation.

On 03/02/2024 at approximately 07:45 AM, the DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with Resident R1. The DON interviewed CNA1 in which he admitted that he (CNA1) restrained the resident.

On 03/02/2025 at approximately 08:04 AM, the DON provided notification to the South Carolina Department of Public Health of the allegation of abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 425107 Department of Health & Human Services Printed: 09/04/2025 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 425107 B. Wing 03/20/2025

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

Sumter East Health & Rehabilitation Center 880 Carolina Avenue Sumter, SC 29150

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 0604 On 03/202/2025 at approximately 08:30 AM, the DON interviewed resident (Resident R1) as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident (Resident R1) disclosed Level of Harm - Immediate that he was lying on his back with his legs bent. He (Resident R1) demonstrated and it was observed that due to jeopardy to resident health or amputations his legs point up into the air. Resident #1 states that when CNA1 entered the room. CNA1 hit safety his (R1s) legs and told him to put them down if he wanted to be changed. The resident did not disclose pain or injury from the open-handed contact but it made him mad and then he, Resident R1, took a swing at CNA1. The Residents Affected - Few resident then demonstrated how CNA1 crossed the residents arms on his upper chest and held his arms.

On 03/02/2025 at approximately 09:30 AM, the DON notified the local police authorities. Officers responded and statements were taken and a report was filed.

On 03/02/2025 at approximately 08:45 AM, the DON contacted the family ad left a message. At approximately 09:00 AM the family returned the call and spoke with LPN1 regarding the allegations.

On 03/02/2025 at approximately 07:25 AM, LPN1 notified the Attending Physician of the allegation of abuse.

On 03/02/2025, the Social Service Director began to monitor the resident (Resident R1) for residual and latent effects.

She reports no latent effects and that the resident (Resident R1) is glad that CNA1 not longer works here.

Actions taken to identify other residents potentially affected:

On 03/05/2025, the Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained.

Systemic Changes:

Based on the following facts:

1) Resident interviews indicated that this was an isolated event.

2) Resident #1's skin audit was negative for marks or bruises.

3) CNA1 admitted both verbally and in his written statement to having restrained Resident R1.

The allegation was substantiated.

On 03/20/2025, the Staff Development Coordinator, DON and or Unit Manager/Coordinator began providing education to staff regarding restraints to include holding a resident's hands down. Education will be provided upon hire, annually and as needed.

All education will be completed by Staff on or before 03/20/2025. Staff will not be allowed to work without completing the training.

On 03/20/2025 the Restraint Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 425107 Department of Health & Human Services Printed: 09/04/2025 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 425107 B. Wing 03/20/2025

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

Sumter East Health & Rehabilitation Center 880 Carolina Avenue Sumter, SC 29150

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 0604 The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the Level of Harm - Immediate audits monthly x 6 months and then quarterly. jeopardy to resident health or safety Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will Residents Affected - Few track and trend her annual education audit and report to QAPI at least annually.

QAPI

On 03/20/2025, an Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone.

The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been take. The Committee approved the addition of restraints as a focus to the new hire process and annual education.

The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 425107