Lake Moultrie Nursing Home

In the surveyor’s words

From the most serious findings on record at Lake Moultrie Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jan 22, 2025

  Based on interview, record review, and facility policy review, the facility failed to ensure physician orders matched the resident's documented end of life wishes for one of 20 residents (Resident (R) 71) reviewed for code status out of a total sample of 20. Specifically, R71's representative chose for R71 to have a Do Not Resuscitate (no cardiopulmonary resuscitation (CPR) in case of a medical emergency) status. Five days later, R71 chose to have full code status (perform CPR in case of a medical emergency); however, the physician's orders were not updated to reflect the resident's choice. This placed R71 at risk of not receiving CPR in the event of a medical emergency and placed the resident at risk for serious harm, up to and including death. […]

• Actual harm, isolatedF689Apr 6, 2023

  Based on record review, interview, facility document review, and facility policy review, the facility failed to consistently formulate and/or implement appropriate fall interventions for 1 (Resident #31) of 3 residents sampled for falls. Specifically, the facility repeatedly provided Resident #31, a resident with severe cognitive impairment, instructions to request assistance in response to multiple falls. In addition, the facility failed to consistently provide a sitter as directed in Resident #31's care plan due to lack of staff availability. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2021

  Based on observations, interviews, and policy review, the facility failed to ensure to label opened items in the walk-in freezer; failed to discard food in the walk-in refrigerator by the use by date; failed to ensure damaged items in the walk-in refrigerator were discarded; and failed to ensure that a hands-free trashcan was available for staff to prevent possible cross contamination. This deficient practice had the potential to effect 66 of the 68 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Receiving and Storage, revised ,d+[DATE], revealed foods shall be received and stored in a manner that complies with safe food handling procedures; 2. […]

• No harm, potential for more than minimal, patternF880Sep 17, 2021

  Based on meal observations, interviews, and facility policy review, the facility failed to ensure that staff washed their hands and/or used hand sanitizer between residents to prevent cross contamination. This affected a total of seven (7) residents (Residents #12, #16, #21, #32, #34, #58 and #65) and one (1) of two (2) wings (south wing). The total sample size was 38. Findings include: Review of facility policy titled Handwashing/Hand Hygiene with revised date August 2019 revealed to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water before and after assisting a resident with meals. During lunch observation on the South Wing on 9/14/21 between 12:30 p.m. and 1:15 p.m. […]

• No harm, potential for more than minimal, isolatedF759Mar 12, 2026

  Based on facility policy review, record review, observation, and interview, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility made 3 medication errors out of 27 opportunities, affecting 1 (Resident (R)4) of 6 residents reviewed during the medication administration task, resulting in a medication error rate of 11.11%. Findings included: Review of the facility policy titled, Administration Procedures for All Medications, revised on 02/25/2025, indicated the purpose was, To administer medications in a safe and effective manner. The policy also indicated, Q. Notification of attending physician: 1) Consistent refusal of medications or as clinically indicated. […]