Every finding on record at Kempton Of Charleston

Based on facility policy review, record review, observation, and interview, the facility failed to honor Resident (R)38's request for a room change after another resident entered her room uninvited for 1 of 1 residents reviewed for choices and Resident-to-Resident interactions.Findings include:Review of the facility policy, Abuse Prohibition with a revision date of 02/2024, revealed, General Prevention.Situations will be discussed with employees in which abuse is more likely to occur and how to intervene, such as.b. Characteristics of residents which have the potential to trigger an abusive incident such as wandering into other resident rooms.1. Review of R38's admission data revealed she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, age-related osteoporosis (loss of bone density) with current fracture in the vertebrae (bones of the spine), unspecified dementia with mood disturbance, chronic kidney disease, and atrial fibrillation (abnormal heart rhythm).Review of R38's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/26, revealed she had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated she had moderate cognitive impairment. R38 had a mood severity score of 00, which indicated she had no symptoms of depressed mood. She exhibited no behavioral symptoms or wandering.Review of R38's Care Plan revealed she had a focus area of, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia with mood disturbance. Her goals were to communicate basic needs on a daily basis and maintain current level of cognitive function.2. Review of R29's admission data revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, traumatic subarachnoid and subdural hemorrhages (bleeding in the brain), falls, alcoholic liver disease, and unspecified dementia without behavioral disturbance, mood disturbance, psychotic disturbance, and anxiety.Review of R29's admission MDS with an ARD of 07/09/26 revealed he had a BIMS score of 5 out of 15, which indicated he had severe cognitive impairment. He had a mood severity score of 00, which indicated he had no symptoms of depressed mood. He exhibited wandering behaviors during 1 to 3 days of the look-back period. Review of R29's Care Plan revealed a focus area of, I am at risk for elopement r/t wandering activity, confusion, unaware of safety needs. His goal was for risks of elopement to be minimized through current interventions over the next 90 days. Interventions included having R29 wear a WanderGuard and providing him with diversional activities during times of restlessness and wandering. During an observation on 07/21/26 at 12:30 PM, R38 was observed sitting in a chair watching TV. R38 answered questions appropriately and conversed with Surveyor without signs of confusion. R38 became louder and more animated with her hands and expressions when talking about R29 entering her room uninvited. During an observation on 07/22/26 at approximately 10:35 AM, R38 was observed sitting in a chair in the common area. R38 spoke with Surveyor again and was able to answer questions appropriately with no signs of confusion. During an interview on 07/21/2026 at 12:30 PM with R38, she revealed R29 wheeled into her room uninvited. She further revealed she would prefer that he not do this again. When the incident happened, she stated she hollered and pressed her watch call button to get the attention of the staff. She stated she feels nothing has been done to prevent it from happening again. She revealed she would prefer to be in a room closer to the nursing station. She stated she did not like the location of her room because it was far away from the nursing station and tucked around the corner. She stated she expressed her displeasure of her room location and her desire to change rooms, but she was told no other rooms were available. During an interview on 07/22/26 at approximately 10:35 AM with R38, Surveyor asked R38 if she still wanted to change rooms. She revealed she is looking to get out of the facility. R38 stated when R29 came into her room uninvited, she told him to stay out of her room. She stated she was upset about it because she did not feel there was any security to prevent it from happening again. She stated she hollered and hollered when it happened, but no staff came to help. R38 revealed she understood it was not R29's fault due to his dementia, but she did not want him to enter her room again.During an interview on 07/22/26 at 12:40 PM with Social Worker (SW), he revealed R38 told him she was unhappy with her room. He stated R38 was a resident in the facility before, and she did not like her room then either. In response to her request for a room change, SW revealed he told R38 her current room is close to the Certified Nurse Assistant (CNA) desk and then redirected her. He revealed Admissions Director (AD) is in charge of room assignments and coordinating the admissions and discharges. He stated he cannot override her. Surveyor asked SW if he had spoken with AD about R38's concerns of R29 entering her room uninvited and her dissatisfaction with the location of her room. SW revealed he did not. He stated he told R38 that her room was a large room, and if they changed her room, the new one would be half the size of her current room. SW confirmed he was aware of R29 entering R38's room uninvited. He stated the incident happened during shift change when a CNA was not at the CNA station outside her room. SW revealed he had a lengthy discussion with R38 informing her that R29 has dementia. He stated he told R38 that R29 is harmless, and she can keep her door closed if she does not want him to enter her room. Surveyor asked if he spoke with anyone else about changing her room to prevent R38 from having R29 enter her room again. Social Worker revealed he did not.During an interview on 07/22/26 at 3:45 PM, AD revealed room changes are not requested that often. She stated if the Resident is their own responsible party (RP), they can request a room change. If the Resident is not their own RP, she would have to speak with person who is the RP. She would discuss the room change with the RP and then honor their wishes. AD revealed there had never been a time when a room change could not be done. She specified the room change may not be able to be done that day, but it could be done as other Residents are discharged , which is often. AD revealed room changes are discussed in their administrative morning meetings, so everyone in administration is notified. To make a room change happen, she stated she would work closely with SW. She revealed room change requests can come from several sources, including SW, nurse, and even a family member. AD confirmed she did not recall being told R38 wanted a room change or hearing about R29 entering R38's room uninvited. AD revealed had she known about R38 wanting a room change or having had another Resident enter her room uninvited, she would have definitely worked towards a room change for R38. During an interview on 07/23/26 at 10:45 AM with the Administrator and Minimum Data Set (MDS) Nurse, who was covering for the Director of Nursing, Administrator revealed room changes are most often requested because of roommate issues. He stated because their rooms are private, except for two of them, they do not get many requests for room changes. MDS Nurse revealed R29 has a WanderGuard on because he roams. She stated the WanderGuard was implemented on 07/06/26. She described R29 as redirectable and harmless. She stated the facility does not have a lock down area, and it would not be appropriate to lock his door to prevent him from leaving his room. Both Administrator and MDS Nurse agreed R38 has the right to feel comfortable that she will be free of other residents entering her room uninvited. MDS Nurse revealed R38 is scheduled to be discharged next week, but she will speak to R38 to see if she still wants to change her room. MDS Nurse revealed interventions used to prevent R29 from going into other Residents' rooms include redirecting him and keeping him by the nursing station. She stated at the time of his admission, they could not put him in a room closer to the nursing station due to availability.

Based on observation and interview, the facility failed to ensure rooms were free from dust, debris, and spills on the floors in 3 of 5 rooms reviewed for cleanliness and homelike environment.Findings include:During an observation on 07/21/26 at approximately 2:15 PM in room [ROOM NUMBER], revealed black debris scattered throughout the floor. Some of the black debris could be loosened from the floor, but some remained stuck to the floor. During an observation on 07/21/26 at 2:35 PM in room [ROOM NUMBER], revealed crumbs, an alcohol swab, and paper debris noted on the floor under the bed. Spill marks were noted on the right side of the bed near the window and the left side of the bed. During an observation on 07/22/26 at 9:15 AM in room [ROOM NUMBER], revealed visible dust and crumbs under the bed. During an observation on 07/22/26 at 9:28 AM in room [ROOM NUMBER], revealed a paper clip, covers for disposable medical supplies, and crumbs on the floor. A hospital arm band was noted behind the head of the bed on the floor. On the right side of the bed by the windows and intravenous medication (IV) pole and on the left side of the bed, a dried black substance with shoe prints was noted. The area on the right side of the bed was approximately 5 inches in diameter and was sticky when walked on. The area on the left side of the bed was approximately 3 inches in diameter. During the observation, Housekeeping Aide (HA) entered the room with a non-aerosolized spray and a cloth. After several minutes, HA exited room to retrieve a mop. HA re-entered room with a mop in hand. During an observation on 07/22/26 at 9:52 AM in room [ROOM NUMBER], revealed the debris and dried black substance stains on the floor that were observed earlier remained present and visible.Surveyor attempted to interview the HA by herself but was unable to due to a language barrier. During an interview on 07/22/26 at 10:00 AM with Housekeeping Director (HD), she revealed the residents' rooms are cleaned daily. They sweep, mop, and sanitize the rooms every day. She revealed she was aware they need to get the floor cleaner to deep clean and polish the floors. During the interview, Surveyor took HD to room [ROOM NUMBER] and showed her the debris and dried black substance stains on the floor. Surveyor also showed HD the dust and crumbs under the bed in room [ROOM NUMBER]. Surveyor then showed HD the black debris and black spots on the floor in room [ROOM NUMBER].During an interview on 07/22/26 at 10:15 AM with HA and HD, HA indicated to HD that she had not yet swept and mopped rooms 525-529. She revealed she had not mopped room [ROOM NUMBER] because the Resident's young grandson was present in the room. She stated she had swept and mopped room [ROOM NUMBER] yesterday prior to Surveyors arriving. HA stated she always cleans under the beds when cleaning the rooms. HD revealed housekeeping cleans the rooms one time a day. If something happens, such as a spill, after the room is cleaned by housekeeping, it is usually nursing's responsibility to clean it up. During an interview on 07/22/26 at 10:45 AM with Minimum Data Set (MDS) Nurse, who was covering for Director of Nursing, and Administrator, MDS Nurse revealed the nursing staff will clean up little spills or messes in between housekeeping cleanings. She stated it just depends on the size of the mess or spill. If it is big, then they would put a ticket in to have housekeeping do an extra cleaning.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure Resident (R)17's catheter bag was stored off the floor and properly secured to an appropriate fixture to minimize the risk of contamination and infection. This deficient practice was identified for 1 of 1 resident reviewed with an indwelling urinary catheter.Findings include:Review of the facility's policy titled, CCRC Infection Prevention and Control Standards, with a revision date of 12/2020 states, It is the policy of this facility to implement this infection prevention and control program to minimize the risk of infection to the residents and staff.Review of R17's face sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, retention of urine, pneumonia, heart failure, and encounter for fitting and adjustment of urinary device. Review of R17's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/26 revealed she had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating that she is cognitively intact. Further review of the MDS revealed that she had a bladder appliance of an indwelling catheter.Review of R17's Physician Orders revealed she has an active order, dated 07/06/26 for, 16fr Balloon Size 10ml diagnosis: retention.Review of R17's Care Plan revealed a focus area of, I have an Indwelling Foley Catheter: Retention of Urine, with an initiation date of 07/09/26. A goal stating, I will be/remain free from catheter-related trauma through review date, was indicated. During an observation on 07/21/26 at 11:23 AM, revealed R17 lying in her recliner chair with her covered catheter bag on the right side of the chair, on the floor.During an observation on 07/22/26 at 9:18 AM, revealed R17 lying in her recliner chair with her covered catheter bag on the right side of the chair, on the floor.During an interview on 07/22/26 at 11:30 AM, Licensed Practical Nurse (LPN)1 revealed that they provide catheter care every shift, they check her Statlock during the day to make sure it is attached appropriately, and the bag is changed weekly. She includes that they usually attach the catheter bag to the wheelchair when she is in her chair and it should never be on the floor.During an interview on 07/22/26 at an unspecified time, Registered Nurse (RN)3 revealed that R17's catheter bag should never be on the floor because that presents an infection control problem. She includes that the bag is usually on her recliner or they try to keep it on the bottom of the walker. She also states that they check it every time they go into her room. During an interview on 07/23/26 at 9:27 AM, Certified Nursing Aide (CNA)1 revealed she is responsible for emptying R17's catheter bag, providing the output, and observing for any discoloration or cloudiness of the urine. She stated that she usually places the hook of the bag on the bed or her wheelchair and it's not to be placed on the floor. She states that the only time it may be on the floor is if R17 is not able to move and it would fall over when she is sitting in the chair.During an interview on 07/23/26 at 12:16 PM, the Infection Preventionist (IP) revealed that she clips the catheter bag to the bed or always hangs it on the bottom of the wheelchair with a privacy bag, and it is not to be put on the floor. She includes they don't usually have a lot of residents with catheters, and they currently only have two. She states they usually do weekly or monthly education in reference to infection control and teachable moments are presented as needed. She also states that she is unsure if R17 is removing the catheter bag and putting it on the floor but she also has not seen or heard that she has done that before.During an interview on 07/23/26 at 12:39 PM, with the MDS Coordinator revealed that the Care Plan was initiated on 07/13/26 to encourage the resident to not put the catheter bag on the floor. The MDS Coordinator was informed that the intervention of the Care Plan was input into the system on 07/22/26 and asked what prompted the update to the Care Plan. The MDS Coordinator included that she updates the Care Plan as information is provided to her by staff or families as it is a living, breathing tool and all information provided could be helpful.

Based on record review, observations, and interviews, the facility failed to maintain an effective infection control and prevention program for one of three residents (Resident (R) 14) reviewed for indwelling urinary catheters out of 12 sampled residents. This failure placed the resident at an increased risk of developing an urinary tract infection (UTI). Findings include: Review of R14's undated Admission Record, found in the resident's electronic medical record (EMR) under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included urinary retention. Review of R14's admission Minimum Data Set (MDS) with an Assessment Reference (ARD) Date of 04/05/25 and found in the EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated R14 had a urinary catheter in place in his bladder. Review of R14's Physicians Order, dated 04/03/25and found in the EMR under the Orders tab revealed an order for the resident to have a Foley Catheter Size 16 French with 10cc (cubic Centimeter) Balloon in his bladder to allow him to urinate. Review or R14's Indwelling Catheter Care Plan, dated 04/04/25 and found in the EMR under the Care Plan tab revealed R14 had an indwelling urinary catheter. The care plan goal indicated R14 would show no signs or symptoms of urinary infection through the next review date. Observation on 05/04/25 at 1:57 PM revealed R14 was lying in bed. The resident's catheter tubing was lying directly on the floor. Observation on 05/05/25 at 11:27 AM revealed R14 was sitting in his wheelchair. The resident's catheter tubing was directly touching the floor. Observation on 05/05/25 at 12:00 PM revealed R14 was transferred from his wheelchair to his bed. The catheter tubing was directly touching the floor during the transfer. Observation and interview with Certified Nursing Assistant (CNA)1 and Licensed Practical Nurse (LPN)1 on 05/06/25 at 8:29 AM revealed R14 was lying in bed, and his catheter tubing was directly touching the floor. CNA1 and LPN1 both observed catheter tubing on the floor and stated the tubing should remain off the floor to prevent potential UTIs. During an interview on 05/06/25 at 11:34 AM, the Director of Nursing (DON) stated it was her expectation R14's catheter tubing would have never been in contact with the floor in order to prevent potential urinary tract infections.

Based on review of the facility policy, observation and interview, the facility failed to properly label and store food items in the kitchen. Furthermore, the facility failed to ensure cold foods were held at an appropriate temperature of 41 degrees Fahrenheit or lower to prevent the potential of food borne illness. Findings include: Review of the facility policy titled, Dietary Storage, (Revised ,d+[DATE]) stated, left over foods are properly covered, labeled, dated and refrigerated immediately. Leftovers are discarded after 72 hours unless otherwise indicated. Review of the facility policy titled, Dietary Services, (Revised ,d+[DATE]) stated, All foods will be stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods will be maintained at 135 F or higher and cold foods will be maintained at 41 F or below. Review of the facility policy titled, Dietary Safe Food Temps, (Revised ,d+[DATE]) stated, Food is cooked to its minimum internal cooking temperature or higher. Quality will not be sacrificed. Hot foods is to be held at 135 F or above. Cold foods will be held at 41 F or lower. Food temperatures at the point of services to the resident should be at least 120 F for hot foods at 50 F for cold foods and must be delivered within 30 minutes of leaving the kitchen. Review of the facility policy titled Food Safety: Employee Personal Hygiene, (Revised ,d+[DATE]) stated, All Food service workers, male and female, are to wear hair nets covering all of their hair while in the production, service and ware washing areas, Employees with long hair are to secure their hair up off their neck/back. Employees with very short hair/ bald may wear a cap, that covers all the hair instead of a hair net. Beard guards will be worn covering facial hair. Observation on [DATE] at 10:25 AM revealed hot dogs opened and partly used with no open date in the kitchen. Observation on [DATE] at 10:25 AM revealed in the refrigerator, two quart cartons of half and half, expired on [DATE]. During an interview, the Head Chef (HC) stated, they are supposed to discard by used date. Observation on [DATE] at 10:25 AM revealed an opened, unlabeled and undated package of [NAME] jack cheese and mozzarella cheese. In the freezer, there was a half bag of opened bacon bits, unlabeled and undated. The HC stated, Items that are open should have an open date. Observation on [DATE] at 10:37 AM revealed the freezer reading a temperature of 5 degrees Fahrenheit. Observation on [DATE] at 11:00 AM showed the following food temperatures: Gravy 159 F Green Beans 179 F Tomato Base 204 F Cold Carrot Salad 57 F, re-temp @ 11:18 AM, reading 70 F Pureed burger 118 F Pureed green beans 104 F During an interview on [DATE] at 11:21 AM, Cook 1 stated that he had training to cooking temperatures and the steam line. He stated, The Hot Box has been broken for approximately 8 months and that is why we have an internal temperature. The HC stated, The Hot Box is not broken, The HC stated that they check the temperatures three times a day and provided logs. The Chef did state the 10:20 AM temp was not recorded for today. During an observation on [DATE] at 11:27 AM, the kitchen staff placed the cold carrot salad on top of the transport warmer cart. During an observation on [DATE] at 11:38 AM, the HC re-tested the cold carrot salad on top of the warmer prior to transporting. The temperatures were #1 50 F #2 50 F #3 55 F #4 56 F #5 54 F During an observation on [DATE] at 11:37 AM, the HC replaced the carrot salad with coleslaw. The Coleslaw temperature read 37 F. During an observation on [DATE] at 11:00 AM, 3 of 3 men (HC, Cook 1, kitchen staff) in the kitchen were observed without beard guard mask. During a telephone interview on [DATE] at 12:04 PM, the Registered Dietitian (RD) stated, I do an inspection with the HC once a month. The last inspection was on [DATE]. The RD stated, I usually look at sanitation, labels, refrigerators, dry storage, temperature logs, check test strips, and the pantry to see if it is rotated properly. I know the HC was working on getting in-service records in place. Every month, the Chef conducts an in-service for new employees, after I do the monthly walk through, he gives a re-education for the other employees of findings. During an interview with the HC on [DATE] at 2:54 PM, the in-service sign in sheet dated [DATE] on Sanitation, Procedure for Kitchen Improvements, Dietary Safe Food Temps, & Dietary Storage was reviewed. HC stated, Cook 1 was not in attendance.

Based on review of the facility policy, observation, and interview, the facility failed to ensure that the pharmacy had properly labeled medication to ensure medication expiration dates where visable for 2 medications stored in the medication room. Findings include: Review of the undated facility policy, titled Medication Storage in the Facility revealed. Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The pharmacy dispenses medications in containers that meet legal requirements .Medications are kept in these containers. Outdated medications and those in containers are immediately removed from stock . An observation on 2/28/2024 at 10:15 AM of the Medication Room revealed 2 medications observed with the expiration date obscured. Fluticasone Nasal Spray lot number and expiration date were not seen as the label was partially peeled off. Vitamin B 12 1000 micrograms (mcg) label was also peeled off. The Unit Manager attempted to remove the Pharmacy label that was added to the original label of the Vitamin B-12, but was unable to remove sufficiently to see the manufacturer's expiration date. On 2/28/2024 at 10:25 AM, an interview with the Unit Manager revealed, I will throw away the nasal spray since both the date and LOT number are missing. She confirmed she could not locate the expiration date on the Vitamin B-12 bottle because the pharmacy label covered it.

Based on observation, interview and facility policy, the facility failed to ensure that medication and biologicals that were outdated or without proper labeling were removed from the medication room and resident room for 1 of 1 medication rooms and 1 of 12 resident rooms. Findings include: Review of the undated facility policy, titled Medication Storage in the Facility revealed, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The pharmacy dispenses medications in containers that meet legal requirements .Medications are kept in these containers. Outdated medications and those in containers are immediately removed from stock . An observation on [DATE] at 10:15 AM of the Medication Room revealed 2 medications observed with the expiration date obscured. Fluticasone Nasal Spray lot number and expiration date were not seen as the label was partially peeled off. Vitamin B 12 1000 micrograms (mcg) label was also peeled off. The Unit Manager attempted to remove the Pharmacy label that was added to the original label, but was unable to remove sufficiently to see the manufacturer's expiration date. An observationon on [DATE] at 10:20 AM revealed seven (7) dressing change trays with an expiration date of [DATE]. During an interview on [DATE] at 10:25 AM, the Unit Manager stated, I will throw away the nasal spray since both the date and LOT number are missing. She confirmed she could not locate the expiration date on the Vitamin B-12 bottle because the pharmacy label covered it. She stated, All the dressing change kits had expired on [DATE], we will discard those. An interview on [DATE] at 2:53 PM with the Director of Nurses revealed, 'We discarded the wound kits, I'm not sure where they came from. An observation on [DATE] at 8:20 AM revealed an unknown substance at the bedside of Resident (R)1. The appearance was of white, thick creamy substance in a 30 milliliter (ml) medication cup without a label or date. There was a 4x4 beside it. During an interview on [DATE] at 8:30 AM, Licensed Practical Nurse (LPN)1 said, It looks like Zinc, I'm not sure. He has an order for Zinc Oxide, I'll discard it. She said, It should not be in the room, it should have been used and discarded.