Johns Island Post Acute

In the surveyor’s words

From the most serious findings on record at Johns Island Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 1, 2026

  Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)5 from physical abuse by R4. Specifically, on [DATE] at approximately 4:43 AM, R4, while in a wheelchair, rolled behind R5 placed his arm around R5's neck and began to choke R5. Certified Nursing Assistant (CNA)1, who witnessed the incident, separated both residents. Furthermore, the facility neglected to provide care and services to R5, following the physical altercation. Specifically, the altercation occurred on [DATE] at approximately 4:43 AM, R5 was placed in his room at approximately 5:03 AM. R5 was found in his room unresponsive and with no pulse at approximately 7:35 AM. […]

• Immediate jeopardy, isolatedF684May 1, 2026

  Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to provide appropriate care for Resident (R)5, who had a respiratory care plan and physician orders, after the resident was choked by another resident on [DATE]. Additionally, the facility failed to provide wound care according to professional standards of practice for R8.On [DATE] at 5:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Quality of Care.On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team, validated the facility's corrective actions and removed the IJ. […]

• Immediate jeopardy, isolatedF627Feb 25, 2026

  Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)137 was discharged from the facility to a safe environment.Per a phone interview with R137 and the Local Ombudsman, R137 revealed he was discharged from the facility on 01/22/26 to a home without utilities (water/electricity).R137 indicated this failure has caused his health to decline due to lack of adequate Durable Medical Equipment (DME-devices and supplies that are intended for repeated use and are essential for managing health conditions at home) and appropriate community services (Home Health), for 1 of 2 residents, reviewed for discharge. […]

• Immediate jeopardy, isolatedF600Oct 23, 2024

  Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was free from neglect. Specifically, R1 did not receive care and services, to address the residents therapeutic diet, resulting in R1 expiring. For 1 of 1 resident reviewed for neglect. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide care and services to a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F600. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. […]

• Immediate jeopardy, isolatedF689Oct 23, 2024

  Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was adequately supervised and free from accident and hazards, for 1 of 1 residents reviewed for accidents. Specifically, R1, who was on a therapeutic diet, consumed food from another resident's meal tray that was left on a dining room table, resulting in R1 expiring. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide adequate supervision of a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F689. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. […]