Every finding on record at Retreat at Wellmore of Daniel Island

Based on a review of facility policy, manufacturers' recommendations, observations, and interviews, the facility failed to: 1. Ensure that food items were stored, prepared, distributed, and or served in accordance with professional standards of practice in one of one main kitchen and four of four satellite kitchenettes. 2. Ensure that staff adequately monitored and documented the sanitation levels of all facility dishwasher machines. Specifically, on 03/18/26, the facility was made aware of concerns with the main kitchen's dishwasher following a service repair by Ecolab and continued to prepare and serve meals using dishware that was not properly sanitized in five of five dishwashers reviewed.On 04/16/26 at 4:20 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 04/16/26 at 4:20 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/18/26. The IJ was related to 42 CFR 483.60 - Food and Nutrition Services. On 04/17/26 at 12:52 PM, the facility provided an acceptable IJ Removal Plan. On 04/17/26 at 1:20 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F812 at a lower scope and severity of F.1. Review of the facility policy Food Preparation and Service last revised November 2022 revealed, Food and nutrition employee prepare, distribute, and serve food in a manner that complies with safe food handling practices. Policy interpretation and implementation include: Danger Zone, means temperatures above 41F and below 135F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Food Preparation means the series of operational process involving preparing foods for serving. Food distribution means the process involved in getting food to the resident. This may include holding foods on the steam table or under refrigeration or cold temperature control, dispensing food portions for individual residents, family style and ding room service, or delivering meals to residents' rooms. Thawing frozen food procedures include, foods are not thawed at room temperature, appropriate thawing procedures include thawing in the refrigerator in a drip-proof container. Food preparation, cooking, and holding time/temperatures policies include, food thermometer use to check food temperature are clean, sanitized, and calibrated for accuracy. Food distribution and service procedures include; proper hot and cold temperature are maintained during food distribution and service. Foods that are held in the temperature danger zone' are discarded after four hours. The temperature of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Food and nutrition services staff wear hair restraints (hair net, beard restraints) so that hair does not contact food. All food service equipment will be sanitized according to current guidelines and manufacturers' recommendations. Review of the facility policy titled Food Receiving and Storage last revised November 2022 revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage policies include non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by) date, such foods are rotated using a first-in-first-out system. Refrigerated/Frozen Storage procedures include, all foods stored in the refrigerator or freezer are covered, labeled, and dated (use-by) date. Refrigerated foods are stored in a way that promotes adequate air circulation around food storage containers. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. An initial tour of the Main Kitchen with the Executive Chef (EC) on 04/14/26 from 10:09 AM to 10:26 AM, revealed the following: In the Main Kitchen: Two ovens with an excessive amount of grease buildup. The EC stated that this item is cleaned monthly by dietary staff. 1 bottle of Smucker's Plate Scraper Carmel opened and undated. 1 container of Bay Leaves that was opened and dated 11/15/24, during interview with the EC he stated seasonings should only be kept for six months 1 bag of powdered sugar opened and undated. The Ice Machine with a black substance on the inside of the right panel. In the Walk-In Cooler: 1 9lb container of Glorious Morning Frozen Gourmet Muffin Batter - not dated when opened 1 bag of crumbled feta cheese - not dated when opened 1 box of Celery that was observed to be wilted 1 box of Lettuce that was observed to be wilted and was received by the facility on 03/31/26 1 slab of pork that was observed defrosting, blood was observed actively dripping on the Walk-In Cooler floor, there was no observation of this item in a drip-container/pan. In the Dry Storage Room: 3 bags of granola opened and undated. 1 25 lb. bag of Organic Yellow Split Peas open and undated. 1 bag of Cake Mix opened and undated. Gnats flying around/ lying on top of bottles on vinegar on the bottom shelf. Observation of the Walk-In Cooler at 10:26 AM revealed the following: 1 Key Lime Pie opened and undated. 1 bag of crumbled sausage not dated after opening/ not properly sealed to prevent freezer burn. 1 box/bag of cauliflower open and undated and not properly sealed to prevent freezer burn. An observation of the [NAME] Unit Satellite Kitchenette on 04/14/26 at 10:33 AM revealed an excessive amount of build-up of crumbs in the tray storage area. An observation of the [NAME] Unit Satellite Kitchenette on 04/14/26 at 10:37 AM revealed an excessive amount of build-up of crumbs in the tray storage area. An observation of the Folly Unit Satellite Kitchenette on 04/14/26 at 11:50 AM revealed Certified Nursing Assistant (CNA)1 and CNA2 assisting with the distribution of resident meals inside the Kitchenette without a hairnet. During observation CNA2 was observed with a hairnet but was not fully covering approximately 5 inches of her hair. A follow-up observation of the Main Kitchen Dry Storage Room on 04/15/26 at 10:49 AM revealed a second observation of gnats flying around/lying on top of vinegar bottles on the bottom shelf. An observation of the Main Kitchen near the Dishwasher/Drying station on 04/15/26 at 10:51 AM revealed three containers stacked on top of each other preventing drying and/or air flow. During an observation in the Main Kitchen with the EC of the food preparation and service process revealed The EC checking the temperature of baked fish, mixed vegetables and potato fries without using a new sanitizer wipe between each item. The EC then accidentally dropped the digital thermometer and then washed it off in the nearby handwashing sink with hand soap and a sanitizer wipe. The EC was then observed using the digital thermometer to check another container of mixed vegetables in the insulated heated holding cabinet without adequately recalibrating the digital thermometer. During a follow-up observation of the [NAME] Unit Satellite Kitchenette on 04/15/26 at 11:28 AM, of the food preparation and service process, [NAME] (C)1 was observed taking pans of the cooked food from the insulated food cabinet and placing the pans on the countertop without using the steam table to ensure food holding temperatures. During a follow-up observation of the Folly Unit Satellite Kitchenette on 04/15/26 at 11:39 AM, of the food preparation and service process, again revealed C1 plating and serving food without using the steam table to ensure food holding temperatures. The following food items did not meet minimum requirements for holding temperatures: Snap Peas - during initial temperature check was 128F, then had to be reheated in the microwave to 175F Tater Tots - 91F. A second observation of CNA 2 on 04/15/26 at 12:10 PM, again revealed CNA2 wearing a hairnet that did not fully cover her hair. During an interview with CNA2 she stated all staff are required to wear hair protection that fully covers hair while in the kitchen/kitchenettes. During a follow-up observation in the Main Kitchen on 04/16/26 at 10:38 AM, the EC was observed standing over kitchen equipment in use without a beard protector. During a follow-up observation of the [NAME] Unit Satellite Kitchenette on 04/16/26 at 11:37 AM, of the food preparation and service process, Cook2 (C2) and the EC served a resident (unable to verify specific resident) a Chicken Salad Sandwich with an internal temperature reading over 68F (should be below 41F). During an interview with C2 and the EC they were unsure of the appropriate food temperature for this item to be served. A phone interview with the Registered Dietitian (RD) on 04/17/26 at 11:55 AM revealed that they expect for all food items to be labeled and dated after opened, there should be two dates posted on all opened items, the dated it was opened and the use-by date. RD expects that all staff no matter their position to have on hairnets/ beard guards when they enter the kitchen/ kitchenettes. Further stated that all items served in the kitchenettes should be placed on the steam table and then plated. Further stated that the chicken salad sandwich should be served cold/ 41F or below. She expects staff to use a new sanitizer wipe after each food item in temped. RD stated that staff should not use the temperature/sanitizer log as face value, logs should be documented accurately to ensure that the dishwasher is adequately sanitizing. Finally, stated that the tubes on the dishwasher should be replaced every 6 months, will now be add to maintenance list to ensure this is completed. 2. Review of the facility policy titled Dishwashing Machine Use last revised March 2010 revealed, Policy Statement: Food Services staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor of a designers proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: 4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: for Chlorine solution machines, 50-100 Parts-Per-Million (PPM) for ten seconds. 5. A supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. 6. Corrective actions will be taken immediately if sanitizer concentrations are too low. 7. The operator will check temperature using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. 9. If hot water temperatures or chemical sanitizer concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. Review of the [NAME] 201LT Low Temperature Chemical Sanitizing Satellite Kitchenettes Dishwasher Installation/Operational Manual revealed, Model Description, pumped final rinse low temperature chemical sanitizing dishwasher with three built-in chemical dispensing pumps. Maintenance schedule recommendations include, before and during operation, check the temperature gauges during operation so ensure the proper temperature is maintained. Check the chemical supply container level and replenish if necessary. Weekly maintenance includes, inspection all water lines for leaks, check drain for leaks, clean accumulated lime deposits from the heating element, check the scrap screen for damage and cleanliness, clean the chemical supply tubing. Review of an Ecolab Report dated 03/18/26 revealed Service requested, replaced the rent additive dispenser, it was rusted, old, and leaking. Review of an Ecolab Report dated 04/16/26 revealed Service requested, sanitizer line was pinched so I cut out the bad ward of the line and got the sanitizer pumping through in the machine. Review of an Ecolab Report dated 04/17/26 revealed Service requested, second call same issue, temperature issue but also pressure issue. Health Inspection is there and needs service today 04/17/26. Services comments, replaced pressure gauage valve and tested everything multiple times to make sure everything working properly. Review of the Main Kitchen Dish Machine Temperature/Sanitation Log for November 2025, January 2026, February 2026, March 2026, and 04/01/26 - 04/15/26 revealed that the staff failed to monitor/document the PPM for the dishwasher. Review of the Satellite Kitchenettes ([NAME], [NAME], [NAME], Folly Unit) April Dish Machine Temperature Logs revealed discrepancies between PPM sanitation levels and temperature levels than what was observed during the Recertification survey. Review a [NAME] Food Services (Satellite Kitchenettes Dishwashers) Service Call Report dated 04/16/26 revealed 04/15/26 arrived on site and checked in with front desk attendant, spoke with DDS. I was shown each dishwasher needing service, 1st floor Units [NAME] and [NAME] need all new squeeze tube and [NAME] housings. The squeeze tubes failed and caused damage to housings. [NAME] temperature reach appropriate temp but [NAME] temp drop to under 120F. 2nd Floor Units [NAME] and Folly need all new squeeze tubes as well but haven't completely failed yet to damage the pump housings. Parts can be requested and aired the next day and equipment repaired as soon as possible. Observation of the [NAME]'s Unit Satellite Kitchenette Dishwasher on 04/16/26 at 11:51 AM, the dishwasher sanitation level was at 10 PPM. Appropriate level is 50-100 PPM. Observation of the [NAME] Unit Satellite Kitchenette on 04/16/26 at 11:58 AM revealed C1 using cups and plates from the dishwasher to serve residents their lunch meal. Observation of the dishwasher revealed the sanitation level below the appropriate PPM. Observation of the Folly Unit Satellite Kitchenette on 04/16/26 at 12:10 PM revealed the dishwasher not reaching the appropriate PPM. During observation C1 was observed not using the food steam table to ensure appropriate food holding temperatures, at this time all residents had been served on the unit. Follow-up observation of the [NAME]'s Unit Satellite Kitchenette on 04/16/26 at 12:17 PM revealed the dishwasher not reaching the appropriate PPM. Observation of the [NAME] Unit Satellite Kitchenette on 04/16/26 at 12:20 PM revealed the dishwasher not reaching the appropriate PPM. Observation of the Main Kitchen on 04/16/26 at 12:27 PM revealed the dishwasher not reaching the appropriate PPM. A follow-up observation and interview in the Main Kitchen on 04/16/26 at 1:20 PM with the EC revealed that the three-compartment sink is currently not in use/out of order. The EC stated that the facility utilizes the satellite kitchenette dishwashers for smaller items (plates, utensils, cups) after lunch and dinner meals on each unit. Breakfast dishware is brought back down to the Main Kitchen and is cleaned/sanitized in the main dishwasher. Further observation revealed the main dishwasher did not reach the appropriate PPM of 50-100. An interview on 04/16/26 at 1:47 PM with the Director of Dining Services (DDS), Certified Dietary Manager (CDM), and Administrator revealed that all the dishwashers at the facility (Main Kitchen and Satellite Kitchenettes) are low-temperature machines. Dietary Aids are the staff responsible for ensuring dishware is cleaned/sanitized on the unit. The DSS and CDM revealed that facility recently completed a self-audit and determined that the dishwasher in the Main Kitchen was not reaching an adequate sanitation level, the machine was serviced by Ecolab on 03/18/26. The facility was unable to provide audit checks of the Main Kitchen sanitation level to ensure the appropriate PPM was held after the visit. An observation with Kitchen Management (DSS, CDM, EC) on 04/16/26 at 2:28 PM of the [NAME] Unit Satellite Dishwasher revealed the dish machine only was able to reach 110F, observation of the sanitizer level revealed it was below 50PPM at this time. An observation with Kitchen Management on 04/16/26 at 2:32 of the [NAME] Unit Satellite Dishwasher revealed the machine did not reach 120F, observation of the sanitization level revealed it was below 50PPM. An observation with Kitchen Management on 04/16/26 at 2:40 PM of the [NAME] Unit Satellite Kitchenette Dishwasher revealed the machine was only able to reach 115F, observation of the sanitization level revealed it was below 50PPM. An observation on 4/16/26 at 2:43 PM of the Folly Unit Satellite Dishwasher revealed that the machine reached 140F during the rinse cycle, the temperature gauge then dropped to below 120F on the final rinse cycle. Observation of the sanitization level revealed it was below 50PPM. An interview with the Administrator and [NAME] Food Services (Satellite Kitchenettes) Dishwasher Technician on 04/16/26 at 4:25 PM revealed that the squeeze tubes are worn out on all the dishwashing machines in the Satellite Kitchenettes. He further stated that the squeeze tube functions as the part that allows the sanitizer to go into the machine. He was unable to find any record in his system of any services for any of the dishwashers in the satellite kitchenettes. The machines can be serviced/fixed in one day, but it will take a while for the parts to come in. Finally, he stated that if the facility checked the PPM on a daily basis, they would have been able to determine if the machine was not working properly. A phone interview with the Medical Director (MD) on 04/17/26 at 1:50 PM revealed when dishware is not adequately sanitized there is a risk for microorganisms which have the potential to cause illness. Potential illness includes but is not limited to Gastrointestinal (GI) that could cause a resident to become low on fluids and potentially require hospitalization, some microorganisms require antibiotics to be treated. The facility provided an acceptable IJ Removal Plan, which included the following: This letter serves as our formal Immediate Jeopardy (IJ) Removal Plan in response to the identified deficiency F812 regarding food procurement, store/prepare/serve – sanitary. Our facility takes this matter with the utmost seriousness and has implemented the following corrective actions to ensure resident safety and regulatory compliance. I. Ensuring Harm Will Not Occur or Recur: To prevent recurrence regarding food procurement, store/prepare/serve – sanitary, our facility has taken immediate and ongoing actions to eliminate the risk associated with unsafe regarding food procurement, store/prepare/serve – sanitary. These steps include the reassessment of all residents at risk, reinforcement of safety measures, and staff education to ensure proper monitoring and response. All actions taken are designed to provide a safe environment while ensuring adequate food procurement and storage/preparation, and service to all at-risk residents. II. Date of Implementation: While all corrective actions were initiated immediately upon discovery of deficiency, the official implementation dates for specific actions are listed below: 1. April 16, 2026 – 12:09pm Immediately upon discovery of deficient practice the Administrator had the skilled nursing team remove all reusable flatware, cups, coffee pots, ice scoops, hydration station and supplies, plates and any other serve ware. These items were replaced with disposable counterparts for the duration of the lunch service.2. April 16, 2026 – 12:15pm Administrator had the Scheduler/Admin Assistant educate the floor team on non-use of the dishwashers until further notice. This included the use of disposables.3. April 16, 2026 – 12:19pm Director of Dining Services called [NAME] Food Service Repair to come and assess the dish machines on The Retreat skilled nursing kitchenettes (4). Director of Dining Services called Ecolab to service the Main Kitchen Dish Machine. 4. April 16, 2026 – 12:45pm Director of Dining Services went to purchase additional PPM test strips to ensure we had active strips on site. The ones on site at the time of deficient practice were identified as valid through 7/2027; the purchase of additional strips was to ensure accuracy.5. April 16, 2026 – 1:46pm Ecolab arrived on site to service the main dish machine. Technician identified a kink in the line and was able to restore the machine to full service.6. April 16, 2026 – 1:50pm Administrator informed Director of Dining Services that all dinner meals needed to be discarded and we needed to move to an alternative meal; this decision was made to ensure all cooking utensils were properly sanitized. All meals for dinner were discarded. 7. April 16, 2026 – 1:59pm Healthcare Liaison called and spoke to US Foods to confirm that our disposables were ordered as part of our standard order and would be delivered on Friday, April 17, 2026. This was completed out of an abundance of caution in the event the dish machines were not put back in service. 8. April 16, 2026 – 2:14pm Director of Dining Services informed the Chef, CDM, Administrator, and Executive Director that the new meal would be spaghetti with meat sauce, garlic bread, and broccoli – the dessert was fruit crisp. 9. April 16, 2026 – 2:24pm Administrator informed the Survey Team of the meal change.10. April 16, 2026 – 2:44pm [NAME] confirmed via email that their technician would be on site 04/16/26 to service the dish machines in The Retreat kitchenettes (4).11. April 16, 2026 – 3:00pm CDM printed new diet tickets for all meals.12. April 16, 2026 – 3:10pm [NAME] representative arrived onsite to assess the dish machines. He spoke with Director of Dining Services and then the Administrator to him to the kitchenettes. At this time, he determined that the squeeze tubes to the sanitizer needed to be replaced. He also verbally recommended the wheels on the internal squeeze tube system be replaced. 13. April 16, 2026 – 3:18pm Executive Director purchased replacement squeeze tubes for all kitchenette squeeze tubes. The estimated arrival date is 4/18/26. [NAME] will return to install once they are in house.14. April 16, 2026 – 3:35pm-5:45p Dining Team completed proper sanitization of all reusable serve ware. 15. April 16, 2026 – 3:33pm Survey Team Coordinator informed the Leadership Team that they had conferred with the DPH office and were going to call an Immediate Jeopardy citation related to the dish machine sanitization.16. April 16, 2026 – 4:37pm Executive Director notified the Medical Director that the Community was in Immediate Jeopardy.17. April 16, 2026 – 4:43pm Survey Team Coordinator sent Administrator the Immediate Jeopardy template, which was immediately printed and signed by the Administrator.18. April 16, 2026 – 4:49pm DPH Survey Team exited the Community at this time. 19. April 16, 2026 – 4:50pm Administrator had the clinical leadership team do an audit of all 4 kitchenettes to ensure all reusable serve ware had been removed from the kitchenettes, fridges, dish machines, sinks, residents' apartments, and common areas. All removed items were taken to the main dish machine and appropriately sanitized. 20. April 16, 2026 – 4:55pm Executive Director educated the Administrator on F812 regulations and state regulations for proper sanitation and dish machine temperatures and PPM for chemical sanitation.21. April 16, 2026 – 5:19pm Administrator had the clinical leaders and nurses on the floor assess all Members for symptoms of foodborne illness. No Members were identified to be affected by any gastrointestinal concerns. There were no past concerns of foodborne illness or associated Gastrointestinal illness symptoms; this information was reviewed by our Regional Clinical Coach by way of auditing April 2026 case list for infection control. 22. April 16, 2026 – 5:31pm Administrator notified the Ombudsman that the Community was in Immediate Jeopardy.23. April 16, 2026 – 5:45pm Administrator educated the CDM on F812 regulations and state regulations for proper sanitation and dish machine temperatures and PPM for chemical sanitation. 24. April 16, 2026 – 5:45pm Administrator educate the [Facilities] Leadership team on F812 regulations and state regulations for proper sanitation and dish machine temperatures and PPM for chemical sanitation. Administrator assigned Leadership education groups for whole house education for everyone in the community. 25. April 16, 2026 – 6:07pm Administrator, Director of Dining Services, and Executive Director received the following report from: 4-15-26 DORT. Arrived on site and checked in with front desk attendant. Spoke with [Director of Dining Services] and [Administrator]. Was shown to each dishwasher needing service. First floor dishwashers ([NAME] and [NAME]) need all new squeeze tubes and pump housings. The squeeze tubes failed and caused damage to housing. [NAME] temped correctly but [NAME] temps dropped to just under 120 degrees. Technician turned thermostat up to help it achieve better temps and it was confirmed to hold proper temperature. Element is pulling correct amp draw. Second floor dishwashers ([NAME] and Folly) need all new squeeze tubes as well but haven't completely failed yet to damage the pump housing and when verified, [NAME] and Folly dishwashers held proper temperatures. Explained my findings to [Administrator] and [Director of Dining Services]. They requested parts to be next day aired, and equipment repaired as quick as possible. Emergency repairs and express parts shipping were all authorized by Executive Director. 26. April 16, 2026 – 6:28pm-7:23pm The Leadership team began education with all team members in house on F812 regulations and state regulations for proper sanitation and dish machine temperatures and PPM for chemical sanitation. The Director of Dining Services and Executive Chef included their education in English and Spanish. The Director of Dining Services and Executive Chef also conducted education on the proper testing method of PPM and the need for this testing to be completed daily and logged. 27. April 16, 2026 – 6:33pm The Executive Director send a regroup message to all staff that included PDF versions of the Education and a summary. This Education was sent to all team members by e-mail, text, and phone.28. April 16, 2026 – 6:40pm The Executive Director sent a regroup message to all Residents, Members, Families, and Responsible parties that informed of the dishwasher concerns, the switch to disposables for lunch, the cancellation of the The Chef's Dinner, and the switch to an alternative safe meal. The message included that all meal service would continue per the norm starting 14/17/2026 and that the main dish machine would be used for cleaning of all serve ware.29. Ongoing – Administrator and/or designee will conduct weekly audits of the temperature and PPM logs for 4 weeks, then monthly x2 months. Audit results will be presented to the QAPI committee monthly. Audits will continue until 100% compliance is reached. 30. Ongoing – Director of Dining Services and/or Designee will conduct daily audits of the dish machine temperature and PPM logs weekly for 4 weeks, then monthly x2 months. Audit results will be presented to the QAPI committee monthly. Audits will continue until 100% compliance is reached. III. Identifying Those Affected or at Risk: All Members in skilled nursing had the potential to be affected. A root cause analysis was completed. IV. Systemic Process Changes to Prevent Recurrence: The facility has taken the following steps to alter systemic failures and prevent future adverse outcomes: 1. Increased Monitoring and Audits:a. CSA, DDS and/or Designee will conduct audits daily for two weeks, weekly for eight weeks, and monthly for three months or longer until 100% compliance is met to ensure proper sanitation. All negative findings will be corrected immediately. Involved Team Members will be reeducated immediately. b. We will track compliance by reviewing the audit tool. c. Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations. 2. Enhanced Staff Training and Education:a. All staff will be re-educated by CSA and/or designee on F812 regulations and state regulations for proper sanitation and dish machine temperatures and PPM for chemical sanitation policies.3. Family and Resident Engagement:a. Families and residents have been provided notification on the dish machine concerns. The facility is alleging compliance as of 04/17/26.

Based on observations, record reviews, interviews, review of the facility policy and South Carolina Board of Nursing regulations, the facility failed to ensure that no significant medication errors occurred for 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F550, F759 and F880.)Findings include: Review of the facility policy titled, Administering Medication, revised 2019 states Medications are administered with prescriber order . Review of the facility policy titled, Central Venous Catheter Flushing and Locking revised June 2025 states The purposes of this procedure are to maintain patency of central venous catheters/access devices (CVADS), prevent mixing of incompatible medications and solutions, and ensure entire dose of solution or medication is administered into the venous system. and Verify with State Nurses Practice act the scope of practice for RNs (Registered Nurses) and LPNs (Licensed Practical Nurses regarding this procedure. Review of the South Carolina Board of Nursing regulations revealed Licensed Practical Nurses (LPNs) may administer specific IV (intravenous) medications and fluids, provided they have completed specialized training and act under the direct supervision of a Registered Nurse (RN) or physician. Review of the Electronic Medical Record (EMR) revealed R45 had been admitted to the facility on [DATE] with diagnoses of septicemia and bacteremia and had been placed on enhanced barrier precautions. On 04/14/26 at approximately 10:40 AM, during medication pass observation, Licensed Practical Nurse (LPN)1 stated LPN2, was going to help him administer Rocephin [an antibiotic] to R45 through a PICC (peripherally inserted central catheter) line, because he had not given medications this way before. On 04/14/26 at approximately 10:48 AM, LPN1 and LPN2 went to R45 who was sitting in the common area and administered Heparin Lock Flush 50 USP (United States Pharmacopeia)/5 ml (milliliters) into the PICC line first, then secondly administered Normal Saline (Sodium Chloride) 0.9% (percent), 10 ml and lastly attached ceftriaxone (Rocephin) 2 Grams contained in a premixed [NAME] intravenous infusion container to the PICC line. During administration of these three medications, neither LPN1 nor LPN2 were wearing PPE (personal protective equipment) and both touched R45. During administration of these three medications, four staff members and one visitor walked by in the hallway while looking into the common area while the medications were being administered. On 04/14/26 at 10:56 AM, LPN1, when asked, verified R45 was in a common area, that PPE had not been used when the 3 medications had been administered to R45 and acknowledged that Heparin had been given first, then Normal Saline prior to the Rocephin (ceftriaxone) being administered. On 4/14/26 at approximately 11:06 AM, during medication reconciliation, a review of the EMR (electronic medical record) revealed an order for Ceftriaxone Sodium Solution reconstitute 2 Gm (grams), Use 2 gram intravenously every 24 hours for infection for 14 days dated 4/7/2026 08:00, but there were no physicians order for Heparin or Normal Saline. On 04/15/26 at approximately 10:40 AM, further review of the EMR revealed a physician's order dated 4/15/2026 10:30 which read SASH (Saline - Administer - Saline -Heparin) Protocol: Please ensure SASH protocol is followed for central line infusions. Scrub lumen hub 10 ml normal saline flush before medication administration Scrub lumen hub Administer Medication Disconnect medication Scrub lumen hub give 10 ml normal saline flush after medication Scrub lumen hub Give 5ml (50 units) Heparin flush (as ordered Place Kuros disinfectant cap over lumen(s). On 04/15/26 at approximately 12:25 PM, Registered Nurse (RN)1 stated the facility has a training issue with batch orders causing them not to populate standing physician orders to the EMR. He acknowledged he had entered standing orders (SASH) for R45 today and that there were none in the EMR on 4/14/26 at the time the 3 medications had been administered. When he was informed by the Surveyor that Heparin had been administered first, then Normal Saline, he stated that was not how it should be done. On 04/16/26 at approximately 9:04 AM, LPN1 stated there was no order on the MAR (medication administration record) for Heparin or Normal Saline related to the Rocephin order and was unclear as to how he had chosen to administer those 2 medications. He stated again that he had never given an intravenous drug through a PICC line and that's why he had asked LPN2 to help him. He stated he had been trained on resident privacy, enhanced barrier precaution, but had not been trained on intravenous drug administration. On 04/16/26 at approximately 11:07 AM, RN2, the Director of Nursing (DON), stated there was no order for Heparin or Normal Saline in the system at the time the medications were administered on 04/14/26 and that LPN2, an agency nurse, was failing to have orders, including batch orders entered and double checked into the EMR. On 04/17/26 at approximately 8:48 AM during a telephone interview, RN2 (DON) stated again that LPN2 is an agency nurse and that she has no knowledge of LPN2 having received any training related to administering intravenous medications and that when LPN1 asked for help because of his inexperience, he asked the wrong person.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure meals were served according to the prescribed diets during two lunch meals for Resident (R) 33. Findings Include:Review of the facility policy titled, Tray Identification, with a revised date of 04/07, revealed, 2. The Food Services Manager will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents.Review of R33's face sheet revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, cerebral infarction (stroke), cerebellar stroke syndrome, dementia, and dysphagia (difficulty swallowing). Review of R33's annual Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 04/06/26 revealed R33 had a Brief Interview for Mental Status (BIMS) score of 07/15, which indicated R33 had severe cognitive deficit. R33 needed setup assistance with eating and experienced coughing or choking during meals. Review of R33's care plan revealed R33 was at risk for alteration in nutrition related to cerebellar stroke syndrome, swallowing issues, use of mechanically altered diet, and consuming less than 75% of his meals. On 04/07/26, the goal was updated to include a regular, mechanical soft (ground meats), nectar thickened liquid diet. Review of R33's orders revealed an order dated 03/12/26 for a regular diet, mechanical soft with ground meats texture, nectar/mildly thick consistency. An order for aspiration (when food or liquid enters the windpipe or lungs) precautions was dated 04/14/26. During an observation on 04/15/26 at 11:25 AM, R33's lunch ticket read, Regular diet, Mechanical soft ground meat, Mildly thick (2)/ Nectar liquids. The ticket also read, Ground Fish Creole, Garden vegetable (d/s), Buttered corn bread, Milk/Beverage - Nectar/ Mild Thick (2), and Swirl pudding parfait as the specific food to be served for that meal. R33's plate contained an intact filet of fish creole (not ground). Surveyor showed Certified Nursing Assistant (CNA)3 R33's plate, and she immediately removed the plate from R33. During an observation on 04/16/26 at 11:45 am, R33's lunch ticket read, Ground Beef & Bean Chili - Nectar/ Mild Thick, Soft cauliflower with cheese sauce, Yellow rice with gravy, Milk/ Beverage- Nectar/ Mild Thick, Soft mixed berry cobbler. R33's plate contained a pile of dark brown semi-solid substance with beans and rice kernels scattered throughout. The cauliflower with cheese sauce and yellow rice with gravy were missing from the plate. When R33 saw the food on his plate, he stated, What is this crap? Surveyor showed CNA3 R33's plate. She immediately removed the plate from the Resident. Surveyor attempted to speak with the [NAME] regarding the meal served to R33. She replied multiple times, He wants it separate? and walked away. During an interview on 04/17/26 at 8:40 AM, Surveyor spoke with the Executive Chef (EC) about R33's meals. The EC revealed he had always been told at this facility that fish is soft enough to be served whole even for residents who have Ground listed on their ticket. He revealed that any meats, chicken, breaded fish, and shrimp are always chopped or ground when ordered. He revealed R33's meal on 04/16/26 should not have been served mixed together. He stated the dietary aides mixed everything together, and he was not sure why because they had been instructed not to do that. He revealed would follow up with the dietary aides to reinforce that meals should not be served that way. During an interview on 04/17/26 at approximately 10:00 AM, CDM revealed she handles more of the dietary clinical issues, and the EC oversees the kitchen. She stated she does assist with meal prep and overseeing plating when needed and when she is in the kitchen. The CDM stated that R33's fish on 04/15/26 should have been ground and verified what was served was not what was listed on the ticket. She revealed R33's lunch on 04/16/26 should not have been served with the mixed.During an interview on 04/17/26 at 10:30 AM, The Administrator stated her expectation that the meal served matches the meal ticket and consistency of the resident's diet. At the end of the day, the meal has to match the ticket.During an interview on 04/17/26 at 12:00 PM with The Dietician, she revealed the facility's belief is if the fish is soft and can be flaked, it can be served whole for dignity and palatability, and she has instructed this to the kitchen staff.During an interview on 04/17/26 at 12:30 PM with The Speech Therapist (ST), she revealed she had treated R33 and was familiar with his medical history. She revealed a ground diet means the food should fit through the tines of a fork. The ST stated she has worked in places where intact fish filets were served to Residents on a ground diet, but the staff flaked the fish immediately after serving the meal because the ability of the Residents to flake the fish appropriately could not be assured. The ST verified that R33's lunch meal on 04/15/26 did not meet the criteria for ground.

Based on observations, record reviews and interviews the facility failed to ensure that privacy was maintained while intravenous medications were being administered to 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F759, F760 and F880.)Findings include: Review of the facility policy titled, Dignity revised February 2022, states Resident are treated with dignity and respect at all times. No policy on Privacy was obtained during the survey process. Review of the Electronic Medical Record (EMR) revealed R45 had been admitted to the facility on [DATE] with diagnoses of septicemia and bacteremia and had been placed on enhanced barrier precautions (EBP). On 04/14/26 at approximately 10:40 AM, during medication pass observation, Licensed Practical Nurse (LPN)1 stated LPN2 was going to help him administer Rocephin [an antibiotic] to R45 through a PICC (peripherally inserted central catheter) line, because he had not given medications this way before. On 04/14/2026 at approximately 10:48 AM, LPN1 and LPN2 went to R45, who was sitting in the common area and administered Heparin Lock Flush 50 USP (United States Pharmacopeia)/5 ml (milliliters) into the PICC line first, then administered Normal Saline (Sodium Chloride) 0.9% (percent), 10 ml and lastly, attached Ceftriaxone (Rocephin) 2 Grams contained in a premixed [NAME] intravenous infusion container, to the PICC line. During administration of these three medications, neither LPN1 nor LPN2 were observed wearing PPE (personal protective equipment) and both had physically touched R45. During administration of these three medications, four staff members and one visitor walked by in the hallway, while looking into the common area, while the medications were being administered. During an interview on 04/14/26 at 10:56 AM, LPN1, when asked, verified R45 was in a common area when medications were administered and privacy had not been provided.

Based on observations, record reviews, interviews and facility policy, the facility failed to ensure that medications were administered pursuant to physician orders for 1 (Resident (R) 45) of 3 residents observed during medication pass. The medication error rate was 8 percent. (Cross reference F550, F760 and F880.)Findings include: Review of the facility policy titled, Administering Medication, revised 2019 states Medications are administered with prescriber order . Review of the Electronic Medical Record (EMR) indicated R45 had been admitted to the facility on [DATE] with diagnoses of septicemia and bacteremia and had been placed on enhanced barrier precautions. On 04/14/26 at approximately 10:40 AM, during medication pass observation, Licensed Practical Nurse (LPN)1 stated LPN2, was going to help him administer Rocephin [an antibiotic] to R45 through a PICC (peripherally inserted central catheter) line because he had not given medications this way before. On 04/14/26 at approximately 10:48 AM, LPN1 and LPN2 went to R45, who was sitting in the common area and administered Heparin Lock Flush 50 USP (United States Pharmacopeia)/5 ml (milliliters) into the PICC line first, then secondly administered Normal Saline (Sodium Chloride) 0.9% (percent), 10 ml and lastly, attached Ceftriaxone (Rocephin) 2 Grams contained in a premixed [NAME] intravenous infusion container to the PICC line. During administration of these three medications, neither LPN1 nor LPN2 were wearing PPE (personal protective equipment) and both physically touched R45. During administration of these 3 medications, four staff members and one visitor walked by in the hallway, while looking into the common area, while the medications were being administered. On 04/14/26 at 10:56 AM, LPN1, when asked, verified R45 was in a common area, that PPE had not been used when the three medications had been administered to R45 and acknowledged that Heparin had been given first, then Normal Saline prior to the Rocephin (Ceftriaxone) being administered. On 4/14/26, at approximately 11:06 AM, during medication reconciliation, a review of the EMR revealed an order for Ceftriaxone Sodium Solution reconstitute 2 Gm (grams), Use 2 grams intravenously every 24 hours for infection for 14 days dated 4/7/2026 at 08:00, but there were no Physician's orders for Heparin or Normal Saline. On 4/15/26 at approximately 10:40 AM, further review of the EMR revealed a Physician's order dated 4/15/26 at 10:30 AM, which read SASH (Saline - Administer - Saline -Heparin) Protocol: Please ensure SASH protocol is followed for central line infusions. Scrub lumen hub 10 ml normal saline flush before medication administration Scrub lumen hub Administer Medication Disconnect medication Scrub lumen hub give 10 ml normal saline flush after medication Scrub lumen hub Give 5ml (50 units) Heparin flush (as ordered Place Kuros disinfectant cap over lumen(s). On 04/15/26 at approximately 12:25 PM, Registered Nurse (RN)1 stated the facility has a training issue with batch orders causing them not to populate standing physician orders to the EMR. He acknowledged he had entered standing orders (SASH) for R45 today and that there were none in the EMR on 4/14/26 at the time the 3 medications had been administered. When he was informed by the Surveyor that Heparin had been administered first, then Normal Saline, he stated that was not how it should be done. On 04/16/2026 at approximately 9:04 AM, LPN1 stated there was no order on the MAR (medication administration record) for Heparin or Normal Saline related to the Rocephin order and was unclear as to how he had chosen to administer those 2 medications. He stated again that he had never given an intravenous drug through a PICC line and that's why he had asked LPN2 to help him. He stated he had been trained on resident privacy, enhanced barrier precaution, but had not been trained on intravenous drug administration. On 04/16/26 at approximately 11:07 AM, RN2, the Director of Nursing (DON), stated there was no order for Heparin or Normal Saline in the system at the time the medications were administered on 04/14/26 and that LPN2, an agency nurse, was failing to have orders, including batch orders entered and double checked into the EMR.

Based on observations, record reviews, interviews, and review of manufacturer labeling, the facility failed to ensure that medications were properly stored in 1 of 4 treatment carts.Findings Include: During an observation on 04/15/26 at approximately 11:32 AM, the [NAME] treatment cart contained one opened container of [NAME] Normal Saline 0.9 percent (0.9%), 100 milliliters (100 mL). The container was dated by the facility as opened on 04/10/2026. The manufacturer's labeling on the container stated Do Not Reuse and Contents STERILE in unopened.package. During a follow-up interview on 04/15/26 at approximately 11:37 AM, Licensed Practical Nurse 3 (LPN 3) inspected the [NAME] Normal Saline container, read the manufacturer's labeling, and stated that it should have been discarded after use rather than being returned to the treatment cart.

Based on observations, record reviews, interviews and review of the facility policy, the facility failed to ensure enhanced barrier precautions were followed for 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F550, F759 and F760). Findings Include:Review of the facility policy titled, Enhanced Barrier Precautions, last revised August 2022, states, Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.Review of the facility policy titled, Infection Prevention and Control Program last revised October 2018 states, Prevention of Infection: a. Important facets of infection prevention include. (3) educating staff and ensuring that they adhere to proper techniques and procedures. (7) implementing appropriate isolation precautions when necessaryReview of the Electronic Medical Record (EMR) revealed R45 had been admitted to the facility on [DATE] with diagnoses of septicemia and bacteremia and had been placed on enhanced barrier precautions (EBP).During an observation of medication administration on 04/14/26 at approximately 10:40 AM, Licensed Practical Nurse (LPN) 1 stated LPN 2, was going to help him administer Rocephin to R45 through a PICC (peripherally inserted central catheter) line because he had not given medications this way before. At approximately 10:48 AM LPN 1 and LPN 2 went to R45 who was sitting in the common area and administered Heparin Lock Flush 50 USP (United States Pharmacopeia)/5 ml (milliliters) into the PICC line first, then secondly administered Normal Saline (Sodium Chloride) 0.9% (percent), 10 ml and lastly attached ceftriaxone (Rocephin) 2 Grams contained in a premixed [NAME] intravenous infusion container to the PICC line. During the administration of these 3 medications, neither LPN 1 nor LPN 2 were wearing PPE (personal protective equipment) and both touched R45.During an interview on 04/14/26 10:56 AM, LPN 1, when asked, verified R45 was in a common area, that PPE had not been used when the 3 medications had been administered to R45.During an interview on 04/16/26 at approximately 9:04 AM, LPN 1 stated again that he had never given an intravenous drug through a PICC line and that's why he had asked LPN 2 to help him. He stated he had been trained in EBP's but had not been trained on intravenous drug administration.During a telephone interview on 04/17/26 at approximately 8:48 AM, RN 2 (DON) stated again that LPN 2 is an agency nurse and that she has no knowledge of LPN 2 having received any training related to administering intravenous medications and that when LPN 1 asked for help because of his inexperience, he asked the wrong person.

Based on review of facility policy, record review, video footage and interviews, the facility failed to prevent accidents/hazards for 1 of 3 residents reviewed. Specifically, on 8/30/25, Resident (R)1 had a successful elopement from the facility. R1 was placed at an increased risk of being struck by a vehicle and/or suffering a heat related and inclement illness.On 09/11/25 at 2:22 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 09/11/25 at 2:22 PM, the Executive Director (ED) was notified that the failure to protect R1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689.On 09/11/25 at 2:22 PM, the survey team provided the Executive Director with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 8/30/25. The IJ was related to S483.25 Quality of Care- F689: Free of Accident Hazards/Supervision/Devices.On 09/11/25 at 4:28 PM, the facility provided an acceptable IJ Removal Plan. On 09/11/25, the survey team validated the facility's corrective actions and determined the facility made good faith attempts at correcting the non-compliance. The IJ is considered at Past Non-Compliance as of 09/03/25. The survey team concluded all corrective actions were put in place prior to arrival onsite.An extended survey was conducted in conjunction with the Complaint survey for non-compliance at F689, constituting substandard quality of care.Findings include:Review of the facility's undated policy titled, Roam Alert Policy and Procedure Version 1.2 revealed, Policy Statement: The Roam Alert Notification System is a Wander Management system used to monitor cognitively impaired individuals with wandering, exit-seeking, or aggressive behaviors. The Member wears a Roam Alert wrist/ankle band signaling device. When the Member is near a monitored doorway and the door is open, an alarm sounds at the door, displays on the Staff Station Computer, and alarms to the direct care staff pagers. Staff shall manage the implementation, maintenance and monitoring according to the following procedures: 1. SYSTEM DESRIPTION AND PARAMETERSa. Each monitored doorway is connected via the [NAME]-Care Nurse Call system to the direct care pagers.b. The direct care pager alerts caregivers to alarms when they are out of hearing range,c. Each doorway that has a keypad has a code that will by-pass the door alarm temporarily.d. Each doorway that has a keypad has a code that will reset the system.e. The code will be given to staff members only and will be changed when needed by the Facility Services Director.f. The Roam Alert Tags are battery-operated with a unique ID number that must be programmed into the [NAME]-Care software.g. The Roam Alert Tag has a 3-year expiration date upon time of purchase)h. Members must be programmed into the [NAME]-Care software and assigned specific tags.2. DETERMINING THE NEED FOR A ROAM ALERT TAG.a. If, at any time the Staff believes a Member is a Wander Risk and needs a Roam Alert tag, the CSA, DON, RCD, or RCC will be consulted to determine if the request is appropriate.3. ISSUING A ROAM ALERT [NAME]. New Member . Review of the facility's policy titled, ELOPEMENT PREVENTION with a revision date of 1/11 (no year) revealed: GENERAL: The community recognizes that other than our designated memory care units, the entrances and exits to all other levels of care are not secure.POLICY: The purpose of this policy is to insure the assessment, identification, and supervision of at risk residents who deliberately elope and those who may wander due to a confused state. It also promotes the immediate and proper response when a resident goes missing by specifying detailed duties and requiring quarterly drill. An elopement is defined as anytime a resident is missing and not located within community's campus within 60 minutes of initial report . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease with late onset, dementia, hypothyroidism, and diabetes mellitus with hyperglycemia.Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating R1 was cognitively impaired.Review of R1's Elopement Assessment noted on his care plan, revised 09/05/25, revealed R1 was at risk for wandering and elopement.Review of the facility's statement dated 09/04/25 revealed, On 8/30/25 at approximately 12:39pm, Life Enrichment Coordinator (later defined as LEL) received telephone call at the front desk from a former employee who stated she was driving by and observed a gentleman out front of the SNF/AL building wearing what appeared to a roam alert and she was worried he could be from the community. LEL (Life Enrichment Leader) immediately left out the front door and went left towards the SNF/AL (Skilled Nursing Facility/Assisted Living) and observed resident near the garages of the adjoining community. Resident continued to propel self forward while in eyesight of the employee and she was able to get him to stop in front of the main entrance of the adjoining community. She was able to redirect him back to community with encouragement and returned him to his room in SNF at approximately 12:49pm. LEL notified ED, Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), and Nursing Station regarding incident. Community On-Call Nurse also provided notification. Staff provided 1:1 to ensure safety after return to floor until a 1:1 sitter could be obtained. The on-call provider and family were notified. The unit nurse, Registered Nurse 1 completed a skin observation, no injuries were sustained, and vital were WNL. New wander risk assessments were completed on all residents. DON onsite to provide education to staff and Administrator/HRD reviewed camera footage to determine a timeline.On 8/30/25 the state agency received an Initial/24-hour report alleging that on 8/30/25 R1 was reported to have an alleged elopement. He is safe, no injuries noted, and he has a 1:1 sitte(r). All exits were assessed by Maintenance to be in good working order. As part of the investigation, immediate education provided to all SNF team members present on the date of incident 8/30/25, all team members were re-educated via Regroup on the roam alert policy, and pager policy, they were also re-educated regarding responding to roam alerts across all service lines, 9/2/25. Immediate interventions taken to reduce the risk of elopement by the IDT (Interdisciplinary Team). At the conclusion of the investigation, it was determined that the elopement was substantiated. He was brought back to the community by the facility team members with no visible injuries. He was then assessed by the nurse and found to have no injuries. Increased supervision was put in place for 72 hours, on-call provider and family were notified.During an interview on 09/11/25 at approximately 11:16 AM, the Executive Director/Administrator confirmed that R1 did elope through the main SNF (Skilled Nursing Facility) exit located on the first floor adjacent to the elevator.During an interview on 09/11/25 at approximately 11:23 AM, the Executive Director and the Care Services Administrator (CSA), via telephone stated, The staff station computer display is in the nursing station overlooking the dining area and when the alarm system is triggered, the computer and the pager are alerted at the same time, and that a pager works throughout the whole property. She stated that they still have concerns about why Registered Nurse (RN)1 did not hear the page, since she had a pager.During an interview on 09/11/25 at approximately 12:11 PM, the Scheduler stated after speaking with R1 and sitting with him, he stated he was trying to leave behind his wife. His caregiver stated she had just left to take his wife home. He wanted to go home to be with his wife. The Scheduler confirmed that his wife had visited that day and stated her office is near the Activity Room, on the first floor, near the main exit.During an interview on 09/11/25 at approximately 12:25 PM, the Life Enrichment Leader (LEL), not LEC as stated in the 5-day report, confirmed her statement as to how she was working the Main Building front desk when she received call from an ex-employee who recognized that a resident was in a wheelchair outside the building heading toward [NAME] Pointe. She went outside and saw him in a non-motorized wheelchair about a block away from the SNF building near some garages and was able to assist him back into the SNF and to his room. She stated it was a hot and humid day with intermittent rain, but it was not raining at the time.During an interview on 09/11/25 at approximately 12:42 PM, the Care Services Administrator (CSA) confirmed the following timeline was developed from the 8/30/25 camera footage review: 12:03 pm - resident propels himself to [NAME] Staff Workroom12:03:37 - resident propels himself down the hallway12:04:18 - resident reaches the elevator lobby on the 2nd floor of SNF and goes out of frame12:04:29 - resident presses button on elevator12:04:33 - resident enters elevator12:04:51 - elevator doors close12:05:03 - elevator doors open on 1st floor12:05:07 - resident exits elevator12:05:50 - resident pushes on doors to exit the main entrance doors of SNF12:06:07 - resident fully exits SNF12:06:11 - SNF door fully closes12:11:05 - resident is fully out of camera view12:38:59 - former employee calls facility to report resident outside of SNF/AL building12:40:00 pm - LEC exits front doors of community to respond to needUpon completion of timeline investigation, it was determined that resident was unattended when he left off the SNF unit.Attempts were made to contact the eye-witness/ex-employee via telephone with no success.During a telephone interview on 09/11/25 at approximately 12:38 PM, RN1 stated that she was working on the [NAME] Unit, on the second floor and had last seen R1 in the dining room, eating lunch, with two Certified Nursing Assistants (CNA)s sitting in attendance and that she had gone on a 15-minute break to visit another nurse on the Folly Unit, also on the second floor. When asked, she stated she was not wearing her pager because she was on break. During an interview on 09/11/25 at approximately 12:54 PM, CNA1 stated that she last saw R1 shortly after 12:30 PM, sitting in his wheelchair, in front of the television, in the dining room, with other residents and that he left wandering in the hallway, near the nursing station and then came back. She stated wandering is his normal habit and is more out of curiosity than exit seeking. On 9/11/25 at approximately 12:58 PM, CNA1 stated that she was not wearing her pager at the time, because she was on break.During a telephone interview on 9/11/25 at approximately 1:06 PM, R1's spouse stated she had visited on 8/30/25 and had been informed after leaving that he had eloped, stating that she still felt he was safe in the facility. On 9/11/25 at approximately 1:36 PM, camera footage provided by the Executive Director was reviewed by this Surveyor showed R1 leaving the facility alone at 12:06 PM, wearing short pants and a short-sleeved tee-shirt, in his wheelchair. The temperature outside was 90 degrees Fahrenheit, with intermittent rain on [NAME] Island, according to Weather Channel records. The facility's Immediate Jeopardy Removal Plan included the following:Date: September 11, 2025Subject: Immediate Jeopardy Removal Team - F689Dear Survey TeamThis letter serves as our formal Immediate Jeopardy (IJ) Removal Plan in response to the identified deficiency F689 regarding resident safety and elopement prevention. Our facility takes the matter with the utmost seriousness and has implemented the following corrective actions to ensure resident safety and regulatory compliance.I. Ensuring Harm Will Not OCCUR or Reoccur: To prevent recurrence of elopement incidents, our facility has taken immediate and ongoing actions to eliminate the risk associated with unsafe wandering and elopement. These steps include the reassessment of all residents at risk, reinforcement of security measures, and staff education to ensure proper monitoring and response. All actions taken are designed to provide an accident=- environment while ensuring adequate supervision for all at-[NAME] residents.II. Date of Implementation: While all corrective actions were initiated immediately upon discovery of the deficiency, the official implementation dates for specific actions are listed below:1. August 30, 2025 - Member, [R1] was returned to his apartment and immediately assessed by the Registered Nurse (RN)1 for any injury. No injuries were identified. Skin checks were initiated for 48 hours, and no injuries were noted. The family was notified. Medical Director was notified, and provider team completed an assessment. Safety checks were completed for the Member for 72 hours. The Community implemented 1:1 sitter immediately following the event. The Pharmacy consultant completed a med review that was provided to the Medical Provider. The Administrator met with the family and updated the Member's care plan. Pending room availability and appropriateness the Community has made the recommendation to move to Memory Care Assisted Living when appropriate.2. August 30, 2025 - New elopement screening conducted for all residents by Unit Nurse.3. August 30, 2025 - Residents assessed by Unit Nurse for ambulatory status and BIMS (Behavioral Interview for Mental Status) level of 5 or below. Roam Alert tags and corresponding physician orders obtained for qualifying residents.4. August 30, 2025 - RN and C.N.A. assigned to Member [R1] were given immediate education on pager and call bell system use by the DON.5. August 30, 2025, and September 2, 2025 - DON (Director of Nursing) completed immediate reeducation to SNF staff in day of incident, 8/30/2025 and All community staff reeducated by CSA on Roam Alert and Pager Policy, 9/2/2025. Working pagers and radios verified for all staff.6. September 2, 2025 - Maintenance staff assessed all exit points to ensure they were in proper working order.7. September 2, 2025 - elopement binders updated by ADON for all service lines.8. September 2, 2025 - Maintenance increased the sound frequency on squealers from 90 decibels to 10 decibels at all SNF exit points.9. September 2, 2025 - Maintenance reviewed [NAME]-Tone monitor volumes and ordered eternal speakers to increase sound of call bells/roam alerts.10. September 3, 2025 - VP of Construction ordered Desk Top pagers that will be secured in hallways to provide additional alert of call bells/roam alerts.11. Ongoing - Upon admission, each resident will undergo elopement screening, including evaluation of ambulatory status by Unit Nurse, to then be reviewed by DON and/or ADON.12. Ongoing - Nursing staff will complete daily Roam Alert Tag audits to verify device functionality, proper placement, and skin integrity monitoring once per shift. Documentation will be maintained in the medical record and Roam Alert List.III. Identifying Those Affected or at Risk: The resident involved in the elopement incident, along with all residents assigned a Roam Alert tag, have been identified as at risk. Immediate interventions were implemented for these residents, including reassessment and reinforcement of monitoring protocols to prevent further occurrences.IV. Systematic Process Changes to Prevent Recurrence: The facility has taken the following steps to alter systemic failures and prevent adverse outcomes:1. Increased Monitoring and Audits:- CSA, DON, and/or Designee will conduct audits daily for two weeks, weekly for eight weeks, and monthly for three months or longer until 100% compliance is met to ensure Roam Alert tags are functioning and in proper use. All negative findings will be corrected immediately. Involved Team Members will be reeducated immediately.- Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations.- The facility's assessment will be updated to incorporate specific Roam Alert system requirements.2. Enhanced Staff Training and Education:- All staff re-educated by DON and CA on elopement prevention policies. Including the proper use of Roam Alert tags, immediate response protocols, and the importance of timely supervision.-New hires will receive elopement training during orientation, and annual refresher training will be conducted for all staff by Administrative Nurse Staff.3. Family and Resident Engagement:-Family input will be incorporated into individualized care plans to enhance elopement prevention strategies at start of admission and will be carried out by the IDT. Through these measures, our facility is committed to maintaining resident safety, addressing all deficiencies, and ensuring ongoing compliance with federal regulations. The facility alleges compliance on 9/3/2025.

Based on observation, interview, and facility policy review, the facility failed to ensure items in the refrigerator, freezer, and dry storage were properly sealed, labeled, and dated. The facility also failed to discard expired items in dry storage. These failures had the potential to affect all 51 residents who consumed food from the kitchen. Findings include: Review of the facility's policy titled Dating for Food Storage revealed, For labeling, dating items requires special attention. All foods that require time and temperature control (TCS) should be labeled with the following: Common name of the food. Date the food was made. Use by date. The following observations were confirmed on [DATE] at 11:00 AM with the Director of Diet (DD) and the Executive Chef (EC): 1. The walk-in cooler had the following: 4 quart clear container labeled Noodles for soup dated ,d+[DATE], with no label. (Only Date). The container was not covered. 4 quart clear container labeled Apricot Glaze with no date. 4 quart clear container labeled Strawberry Sauce dated ,d+[DATE], with no label. (Only Date). 2 quart clear container labeled Salmon dated ,d+[DATE], with no label (Only Date). 4 quart clear container labeled Pimento Spread with no date. 12-quart clear container labeled Chicken Soup with a date of ,d+[DATE], with no label. (Only Date). 6 quart clear container labeled Meatballs with a date of ,d+[DATE], with no label. (Only Date). 4 quart clear container labeled Tomato Paste with a date of ,d+[DATE], with no label. (Only Date). 4 quart clear container labeled Turkey Gravy with a date of ,d+[DATE], with no label. (Only Date). 6 quart clear container labeled Chicken Base with a date of ,d+[DATE], with no label. (Only Date). 4 quart clear container labeled Thickening Agent with a date of ,d+[DATE], with no label. (Only Date). ,d+[DATE]-Gallon ziplock bag of shredded cheese, not in original packaging, not labeled, with a date of ,d+[DATE]. 2. The walk-in dry storage on [DATE] at 11:30 AM contained the following: ,d+[DATE] LB bag of Rigatoni Noodles, opened with no open date. ,d+[DATE] LB bag of Cut Ziti Noodles, opened with no open date. ,d+[DATE] LB bag of spaghetti Noodles, opened with no open date. Wrapped in plastic wrap. ,d+[DATE] LB bag of Curly Wide Eggs Noodles, unsealed/opened with no open date. ,d+[DATE].9-ounce cereal bag of Cornflakes, opened with no open date. ,d+[DATE].9-ounce cereal bag of Raisan Brand, opened with no open date. ,d+[DATE].9-ounce cereal bag of Cheerios, opened with no open date. ,d+[DATE]-lb open container of Hershey's Cocoa Powder with a use-by date of ,d+[DATE]. ,d+[DATE]-lb container of Baking Soda with a use-by date of [DATE]. 3. The walk-in freezer contained the following: ,d+[DATE]-gallon ziplock bag of what appeared to be cut-up beef. No label and no dates. ,d+[DATE]-gallon ziplock bag of garlic bread, not in original packaging, with a date of ,d+[DATE]. During an observation of a 7-tier Non-Insulated Mobile Cabinet on [DATE], revealed the following: 4 loaves of wheat bread with use-by dates of [DATE] (3 loaves) and [DATE] (1 loaf). 2 loaves of white bread, both with a use-by date of [DATE]. 3 loaves of raisin bread, all with a use-by date of [DATE]. These items were confirmed by the DD and EC. During an interview with the DD on [DATE] at 11:42 AM, the DD stated that all dietary staff is responsible for spot-checking and making sure all items in the kitchen are free from expiration. All leftovers must have appropriate labels and must include the date the food item was placed in the container and the date to discard, within 3 days. During an interview with the Director of Nursing (DON) on [DATE] at 8:29 AM, revealed she was unaware of the findings, and her expectations are for all dietary staff to follow regulations when it comes to food storage and labeling. During an interview with the Facility Administrator (FA) on [DATE] at 9:56 AM, revealed that to her knowledge that dietary staff corrected the concerns, and she would review the policies to see what areas the Dietary staff can work on.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure that: 1. Staff practiced proper hand hygiene during meal tray preparation and 2. Prepared food was being held at regulatory temperatures on the serving line for hot and cold foods, in 2 of 4 satellite kitchens. Findings Include: Review of the facility policy titled, Preventing Foodborne Illness- Employee Hygiene Sanitary Practices, with a revision date of November 2022 states, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 6. Employees must wash their hands: g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. 9. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced . Review of the facility policy titled, Food Preparation and Service, with a revision date of November 2022 states, Food and Nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. 4. When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy. Food Preparation, Cooking and Holding Time/Temperatures, 1. The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 5. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy. During an observation on 04/16/24 at 11:44 AM in the first-floor satellite kitchen revealed, Cook1 was in the kitchen beginning to prepare lunch trays. With gloves donned, he intermittently touched other surfaces. He began with touching the mobile Cambro, of which the food is transported, and then drawers for utensils. Next, he picked up the plates to begin plating food. He was then asked to temp the food, of which he grabbed a piece of the fried fish, with the same gloves on, pulled his thermometer from its cover and began to gain a temperature. He failed to clean and calibrate the thermometer prior to inserting in the piece of fish. Temperatures revealed, Cole slaw that was resting on ice, was 60 F, a glass of Apple juice was 50 F, fried tator tots were 110 F, and steamed carrots were 110 F. During an observation on 04/16/24 at approximately 12:15 PM on the second-floor satellite kitchen revealed, Cook2 was in the kitchen preparing to serve trays and acquiring all utensils and plating. Prior to donning gloves, he proceeded to the sink to wash his hands and there was no soap, so he rinsed and dried them and put on gloves. Cook2 removed a small pan with a piece of grilled chicken, he removed it from the pan and placed the thermometer in it, without cleaning or calibrating it. During an interview with the Certified Dietary Manager (CDM) on 04/16/24 at approximately 1:30 PM revealed her expectations for the kitchenette temperatures of foods that are not at safe temperatures is for the food to be brought back to the main kitchen to be reheated. If it is not in the appropriate time and temperature frame, then she would expect that they prepare the resident with a new meal. To ensure foods are held at cold temperatures, ice can be added to the drinks, but she is unsure about the salad temperature and will check on that and provide a response later. During an interview with Cook2 on 04/16/24 at 12:41 PM revealed that he is responsible for ensuring foods are labeled and at correct temperatures, kitchens are stocked up with gloves, dish soap, kitchens cleaned and wiped down, sanitization and at times he rotates areas. He included that proper hand washing includes washing with soap and water for at least 30 seconds and after every change of gloves or any other surface that would present cross contamination. To correctly temp food, he states that thermometers should be wiped with an alcohol wipe before and after temping food and make sure its calibrated. During an interview with Cook1 on 04/16/24 at 12:47 PM revealed he is responsible for cooking, servicing, preparing plates, special orders, and checking meal tickets. Proper handwashing procedures is for them to wash hands first, put on gloves and change gloves after any service. He states that they temp foods daily and to correctly temp foods you should clean the thermometer, temp the food, clean the thermometer, and when finished, place back in the holder. During an interview with Registered Dietician (RD) on 04/16/24 at 2:39 PM revealed that she visits the facility at least once a month and completes a kitchen audit. Her expectations are for them to receive a grade of 'A' or higher for the audits, but areas that are identified that are not satisfactory, she provides them to the Chef or CDM and when she returns the following month, it is within hopes that these areas have been addressed. She stated that the cooks should be checking temperatures during each meal, following all protocols. During an interview with the CDM on 04/17/24 at 8:18 AM revealed that in-services are provided for staff during onboarding and as needed. Some are completed monthly on Relias. All staff has had proper training as to when they are to wash their hands when handling/ preparing food and working with other objects.

Based on staff interviews, facility Registered Nurse (RN) coverage postings, and facility policy review, the facility failed to post RN coverage on daily staffing posted for March 2024 to the current date in April. Findings include: Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, (revised August 2022) revealed: The information required on the form shall include the following: f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g. The actual time worked during that shift for each category and type of nursing staff. Review of the facility staff postings on the skilled units for March 2024 to current date in April revealed that 8-hour RN coverage was not posted. On 04/17/24 at approximately 10:08 AM, an interview with the Director of Nursing (DON) revealed the reason for not posting RN 8-hour coverage is because their current system does not delineate between RN and Licensed Practical Nurse (LPN) hours on daily posting logs. The DON revealed the facility has a new system called Ultimate Kronos Group, UKG, Human Resource system that will designate RN hours. DON revealed on day-to-day coverage, the facility has 3 RNs for 8 hours each shift, Monday through Friday. DON revealed the night shift supervisor is also an RN and works four times a week. The DON revealed she and the Assistant DON (ADON)are always on call and the new UKG system started on 04/01/24 and are building out reports for the facility. The DON further stated there is a designation of responsibility form for the facility, the Care Service Administrator, CSA, and ADON can share with anyone if there are RNs/LPNs in the building, or on shifts. DON revealed an email with all staffing information can be sent if needed. DON revealed requirements for the number of staff hours in the facility needed are being met. DON revealed she did not know how anyone would know if there was an RN or LPN unless they asked staff for their credentials. The DON revealed her expectations for RN posting is she is very present for resident/family. DON reveals she could be reached or ADON can be reached at any time if anyone questions RN coverage. DON revealed the facility is working toward requirements for RNs in relation to proposed change for 24/7 coverage per CMS. On 04/17/24 at approximately 11:15 AM, an interview with the Facility Administrator revealed the Ultimate Kronos Group, UKG, new HR system will be replacing the current HR/scheduling system. He stated, all is in process, once that is done, we will post leadership nursing positions. The Administrator revealed the UKG started on 04/01/24 and the facility is currently running both systems together until UKG is up and fully running.

Based on observation and interviews, the facility failed to ensure commercial dryers were free from lint buildup, which could increase the likelihood of causing the unit to overheat or combust in fire. Findings include: In an observation on 04/16/24 at approximately 11:30 AM of the Central Laundry Room with Certified Nursing Assistant (CNA)2 revealed lint in the tray in the commercial dryer #1 and #2, along with clothing thrown in cubie cubes alongside wall, plastic bins in the middle of the floor, and laundry sitting in washer. During an interview with CNA2 on 04/16/24 at 11:38 AM, she acknowledged the lint in dryer tray and stated this could have accumulated from clothing being completed on last night, but stated she did not know much about the process in this laundry room because she only completes laundry such as clothing on the hall for the residents. This is the laundry room where CNAs complete linens for the residents. In an attempt to observe laundry on 04/17/24 at 7:02 AM in the Central Laundry room revealed a clean and clear room, no clothing in washer but more accumulation of lint in both lint trays in dryer #1 and dryer #2. In an interview and observation on 04/17/24 at 8:00 AM, the Administrator and Director of Nursing (DON), stated laundry is completed at night by CNAs on the hall. The Administrator and DON were shown the lint in the lint trays and acknowledged the lint in the trays in dryer #1 and #2. The Administrator stated the trays are cleaned nightly, and DON obtained the lint logbook which was signed in for April 16, 2024 as being completed. The Administrator stated there is a supervisor for this room, however, essentially the laundry is completed by the CNAs. Later, the Administrator informed there is no specific policy pertaining to lint cleaning of the dryers.

Based on review of the facility policy titled, Hand Washing/Hand Hygiene, and Food Preparation and Service, observations, and interview, the facility failed to ensure proper hand washing during the lunch meal service on 04/15/2024. The facility failed to ensure staff were adhering to safe meal service to residents related to hand hygiene, and enhanced barrier precautions on the [NAME] Hall for 1 of 4 halls observed during the lunch meal service. Findings include: Review on 04/15/2024 of the facility policy titled, Handwashing/Hand Hygiene, revealed the Policy Statement, which reads, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene,. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc) are readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Indications for Hand Hygiene 1. Hand Hygiene is indicated: a. immediately before touching a resident: b. before performing an aseptic task; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment. 4. Single-use disposable gloves should be used: c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 5. The use of gloves does not replace hand washing/hand hygiene. Review of the facility policy titled, Food Preparation and Service, states under the Policy Statement, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Distribution and Service. 5. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents, Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. During an observation on 04/15/2024 at 11:31 AM of the lunch meal on the [NAME] Hall revealed Certified Nursing Assistant (CNA)1 placing resident lunch meal trays on a small cart and going in and out of each resident's room with the meal trays and not cleansing their hands. Continued observation of the lunch meal service on 04/15/2024 revealed a meal ticket blowing off the small cart and falling on the floor, a nurse called the CNA's attention to it and the nurse picked up the meal ticket and handed it to CNA1, who was delivering the lunch meal trays. CNA1 took the ticket and placed it on the meal cart with other lunch trays being delivered to residents. An additional observation on 04/15/2024 at 11:36 AM, of the lunch meal service revealed, CNA1 donning PPE to deliver a tray into a room that was labeled, Enhanced Barrier Precautions (EHP). After delivering the meal tray, CNA1 came out of the room with the gown under their arm, and walked over to the medication cart and put the soiled gown into the trash bin on the medication cart. CNA1 did not wash their hands and continued to serve meal trays. CNA1 started to put on another gown for an EHP room and then placed it in the housekeeping cart that was sitting in front of another resident's room, and with bare hands lifted the cover from the trash and placed the soiled gown in the bin, and lowered the cover. CNA1 then went into another room to deliver a meal tray. Not once during the meal service was CNA1 observed washing or sanitizing their hands. CNA1 went back to the satellite kitchen area and placed another meal tray on the small cart, and with bare hands, opened the straw and placed it in a cup of tea and served it to a resident. During an interview on 04/15/2024 at 11:50 AM with CNA1, they stated that before starting to serve meal trays they had washed their hands well. CNA1 confirmed that they had not washed or cleansed their hands before and after each resident and asked the surveyor, if that was what they were supposed to be doing.

Based on the facility policy titled, Medication Labeling and Storage, observations and interviews, the facility failed to ensure medications that were outdated/expired or incorrectly labeled were removed from storage and not stored with other medications and biologicals used for residents in 2 of 4 medication carts and 1 of 3 treatment carts. Findings include: Review of the facility policy titled,Medications Labeling and Storage, states the, Policy Interpretation and Implementation, under Medication Storage, states: 1. Medications and biological's are stored in the packaging, containers or dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. If the facility has discontinued, outdated or deteriorated medications or biological's, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication Labeling 1. Labeling of medications and biological's dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 10. Only the dispensing pharmacy may label or alter the label on a medication container or package. An observation on 04/17/2024 at 10:12 AM of the Folly Hall medication cart revealed: Acetaminophen 500 milligrams with Lot #251921, manufactured by Major Pharmaceuticals, 14 tablets expired on 04/10/2024. Vitamin D3 50 micrograms, 29 capsules with Lot #S221063, manufactured by Leader Brand Products was expired on 04/13/2024. These expired medications were confirmed on 04/17/2024 at 10:13 AM by Registered Nurse (RN)2. An observation on 04/17/2024 at 10:22 AM of the [NAME] Hall treatment cart revealed, 7 Lemon Glycerine Swabs was expired on 02/2024. Licensed Practical Nurse (LPN)2 confirmed the expired swabs. An observation on 04/17/2024 at 10:40 AM of the [NAME] Hall medication cart revealed a blister pack of the medication, Trazodone 50 milligrams with Lot #E301645, manufactured by Zydus Pharmaceuticals USA, 11 tablets were expired on 03/31/2024. On 04/17/2024 at 10:45 AM, LPN2 confirmed the expiration of the medication. During an interview on 04/17/2024 at 02:10 PM with the Director of Nursing, she revealed that on the blister card for the Trazodone 50 milligrams, the label affixed to the back of the card revealed the expiration date of 03/31/2024 but the front of the card had a receipt date from the pharmacy as 03/2024. She confirmed the label on the back was incorrectly applied by the pharmacy and no one had questioned the label nor the expiration date.

Based on the facility policy titled, Administering Medications, observations and interviews, the facility failed to ensure medications that were not supposed to be crushed were crushed and administered in applesauce. Specifically medications for Resident (R)8 that were clearly labeled as, Do Not Crush or Chew, were crushed by Licensed Practical Nurse (LPN)2 and administered. Findings include: Review of the facility policy titled, Administering Medications, under Policy Statement, reads, Medications are administered in a safe and timely manner and as prescribed. 4. Medications are administered in accordance with prescribers orders, including any required time frame. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. 31. Each nurses' station has a current Physician's Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance (Pharmacy Services) available. Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. During an observation on 04/17/2024 at 08:05 AM during med pass, LPN2 administered, by mouth medications for R8. LPN2 crushed all of R8's medications and placed them in applesauce and went into her room and administered them. LPN2 stated that R8 liked her medications crushed and placed in the applesauce. During medication reconciliation on 04/17/2024 at 08:30 AM revealed the prescribed medications for R8 were observed to be crushed and were ordered as, Do Not Crush or Chew, according to the medication label and physician's orders. During an interview on 04/17/2024 at 09:45 AM with LPN2, she stated that R8 is a choking risk and this is why she crushes all of her medications. During an interview with Registered Nurse (RN)2, this surveyor asked if she had ever taken care of R8 and administered her medications and she confirmed that the had. RN2 was asked if she crushed her medications, and she stated, I crush the ones I can, but some of her medications cannot be crushed.

Based on review of the facility policy titled, Administering Medications, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication error rate was 7.69 percent for 2 out of 26 opportunities for error. Specifically medications for Resident (R)8 that were clearly labeled as, Do Not Crush or Chew, were crushed by Licensed Practical Nurse (LPN)2 and administered. Findings include: Review of the facility policy titled, Administering Medications, under Policy Statement, reads, Medications are administered in a safe and timely manner and as prescribed. 4. Medications are administered in accordance with prescribers orders, including any required time frame. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. 31. Each nurses' station has a current Physician's Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance (Pharmacy Services) available. Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. During an observation and interview on 04/17/2024 at 08:05 AM during med pass, LPN2 administered, by mouth medications for R8. LPN2 crushed all of R8's medications and placed them in applesauce and went into her room and administered them. LPN2 stated that R8 liked her medications crushed and placed in the applesauce. During medication reconciliation on 04/17/2024 at 08:30 AM revealed that the prescribed medications observed to be crushed were not supposed to be crushed, according to the medication label. During an interview on 04/17/2024 at 09:45 AM with LPN2, she stated that R8 is a choking risk and this is why she crushes her medications. During an interview with Registered Nurse (RN)2, this surveyor asked if she had ever taken care of R8 and administered her medications and she confirmed that the had. RN2 was asked if she crushed her medications, and she stated, I crush the ones I can, but some of her medications cannot be crushed.

Based on record reviews, interviews, observations and review of facility policy, the facility failed to ensure that a member of the nursing staff had renewed her Licensed Practical Nurse (LPN) license in a timely manner for 1 of 3 licensed practical nurses reviewed. Finding include: Review of the facility policy titled Licensure, Certification, and Registration of Personnel with a revised date of [DATE] states, A copy of the recertifications (e.g., (for example) annual, bi-annual, etc. (and so forth), as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record. Review of the facility investigation on [DATE] at approximately 12:15 PM revealed that license number 51037 for LPN1, which was originally issued on [DATE], had expired on [DATE] and that the facility did not discover the lapsed license until [DATE]. During an interview on [DATE] at approximately 1:31 PM, the Administrator and the Director of Nursing, in the presence of the facility Executive Director, confirmed that LPN1 was employed at the facility from [DATE] through [DATE] without an active license from the SC Board of Nursing.

Based on observations, interviews and review of the facility policy titled, Food Receiving and Storage, and Sanitation, the facility failed to store, prepare and serve foods under sanitary conditions in 1 of 1 main kitchen. Findings include: An observation during initial tour of the main kitchen on 5/11/22 at 10:15 AM revealed the following: In the dry storage area; there was Risotto and Coconut Flakes opened with no date, several packages of pasta, rice, vanilla wafers all opened with no date. There was 2 packages of cornbread mix in a plastic bag with a green dried substance inside the bag. The walk in cooler had a CVS bag with 3 soft drinks that belonged to staff. The walk in freezer had a bag of breaded Zucchini opened with no date. A large box of herbed butter that was opened and partially used and replaced in the box with no open date. A bag of chicken tenders was opened and partially used with no open date. The mixer has a dried yellowish substance on the bottom where the bowl sits. The can opener has a dried red substance on the base along the side. The ice machine has a blackish substance on the door in the left hand corner. The handwashing sink was in need of cleaning. During an interview on 5/11/22 at 10:15 AM with the Chef and the Dietary Director the above findings were confirmed. Review on 5/11/22 at 12:40 PM of the facility policy titled, Food Receiving and Storage, states under Policy Statement, Foods shall be received and stored in a manner that complies with safe food handling practices. The policies Interpretation and Implementation states: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated, dry storage, unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Review on 5/11/22 at 10:30 AM of the facility policy titled, Sanitization, states under Policy Statement, The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation, states: 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm (parts per million) chlorine solution. b. 150-200 ppm quaternary ammonium compound (QAC); or c. 12.5 ppm iodine solution. Number 11 states, For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow for access of detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. Number 12 states, Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy.

Based on observation, record review, interview, facility policy, manufacturer package insert and manufacturer labeling the facility failed to assure safe medication storage in 3 of 4 treatment carts, 1 of 4 medication carts and 2 of 4 of medication rooms. Findings include: Record review of the facility's policy titled,Storage of Medications, revised [DATE], showed that the facility stores all drug and biologicals in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drug or biologicals are returned to the dispensing pharmacy or destroyed. Review of the PAR package insert for [MEDICATION(S)], [MEDICATION(S)], Purified Protein Derivative (PPD), Diluted, 5 [MEDICATION(S)] units (TU)/0.1 milliliter (ml) stated Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the [NAME] package labeling for [MEDICATION(S)] Packing Strip Sterile ,d+[DATE] inch () x 5 yards (yds) bottle stated Do Not Reuse, Single Patient Use and Contents STERILE in unopened, undamaged package. Review of the Integra MedHoney Gel Wound and Burn Dressing 18.5 Gram (gm) package labeling stated Sterile and Single Use Only Review of the AstraZeneca [MEDICATION(S)] (budesonide and [MEDICATION(S)]) 160 micrograms (mcg)/4.5 mcg Inhalation Aerosol, for oral inhalation use, package insert and labeling stated Throw away [MEDICATION(S)] when the counter reached zero (0) or 3 months after you take [MEDICATION(S)] out of its foil pouch, whichever comes first. Observation on [DATE] at approximately 10:34 AM, inspection of the [NAME] Wing treatment cart showed one opened (integrity seal not intact) bottle of [NAME] [MEDICATION(S)] Packing Strip, ,d+[DATE] x 5 yds, third drawer from the top of the cart. During an interview on [DATE] at 10:43 AM, Licensed Practical Nurse (LPN)1 stated that the bottle had been opened, used during wound care, and returned to the treatment cart. Observation on [DATE] at approximately 08:57 AM, inspection of the [NAME] Wing treatment cart showed one opened (integrity seal not intact) bottle of [NAME] [MEDICATION(S)] Packing Strip ,d+[DATE] x 5 yds and labeled Do Not Reuse and Contents STERILE in unopened, undamaged package located in bottom drawer of the cart. During an interview on [DATE] at 09:05 AM, LPN2 stated the container had been opened and returned to the treatment cart. Observation on [DATE] at approximately 11:52 AM, inspection of the Folly Wing medication room refrigerator showed eleven intravenous bulbs of [MEDICATION(S)] 1 Gm (gram) in NS (normal saline) dated expired [DATE] by the pharmacy. During an interview on [DATE] at 11:59 AM, the Assistant Director of Nursing (ADON) stated that the medication had expired and should have been removed from active storage by the Pharmacist, who visits monthly and that agency nurses do not have a key to the medication room, but can gain access by contacting a facility employed nurse. Observation on [DATE] at approximately 12:05 PM, inspection of the [NAME] Wing medication room refrigerator showed one opened and undated, 1 milliliter (ml) vial of [MEDICATION(S)] ([MEDICATION(S)] 5 TU/0.1 ml, dispensed [DATE], lot C5822AA, and one opened and undated 1 ml vial of [MEDICATION(S)], [MEDICATION(S)] PPD, dispensed [DATE], lot C5823BA. During an interview on [DATE] at 12:11 PM, the ADON stated the two containers had not been dated when opened and was asked to provide a list of all residents receiving [MEDICATION(S)] PPD, including lot number, since [DATE]. The ADON stated that agency nurses do not have a key to the medication room. Observation on [DATE] at approximately 12:33 PM, inspection of the [NAME] Wing treatment cart showed one opened (integrity seal not intact) bottle of [NAME] [MEDICATION(S)] Packing Strip ,d+[DATE] x 5 yds located in bottom drawer and one opened tube of MedHoney Gel 18.4 gm dated by facility as opened [DATE] with the handwritten name for Resident # 39. During an interview on [DATE] at 12:38 PM, LPN3 stated that both the [MEDICATION(S)] and Medhoney containers had been opened and returned to the treatment cart. Observation on [DATE] at approximately 09:55 AM, inspection of the [NAME] Wing medication cart showed one [MEDICATION(S)] Inhaler,160 mcg/4.5 mcg opened and not dated by the facility as to opened or expiration date. A pharmacy applied label for entry of opened and expiration dates was attached and had not been filled in. During an interview on [DATE] at 09:59 AM, LPN4 stated that the [MEDICATION(S)] was currently in-use and had not been dated when opened.

Based on record reviews, interviews, and review of the facility policy titled, Antipsychotic Medication Use, and the Product Monograph Including Patient Medication Information, for [MEDICATION(S)] and additional review of the facility Clinical Protocol titled, Medication Utilization and Prescribing, the facility failed to ensure the antipsychotic medication, [MEDICATION(S)], was not used as a chemical restraint for 1 of 5 residents reviewed for Unnecessary Medications. Findings include: The facility admitted Resident (R)15, a [AGE] year old female, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/11/22 at 9:44 AM of the medical record for R15 revealed she has a history of falls and has fall mats in place at bedside. R15 had a fall on 4/10/22, in which she fell out of bed, while attempting to turn off the light. R15 was sent out to the hospital for a fall with a major injury. At this time, R15 was receiving the antipsychotic medication, [MEDICATION(S)] 12.5 milligrams. R15 does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R15 is also prescribed the medication [MEDICATION(S)] 20 milligrams for depression, [MEDICATION(S)] 1 milligram for anxiety, [MEDICATION(S)] 5 milligrams to aid in sleep, and [MEDICATION(S)] 50 mg for pain. Review on 5/12/22 at 1:11 PM of the hospital visit for the fall on 4/10/22 stated that R15, received a large hematoma to her left upper forehead area, as well as skin tears on her left shoulder, elbow and knee, a dislocated shoulder and a closed fracture of the left elbow. The fall was unwitnessed by staff. Further review on 5/12/22 at 1:45 PM of the Comprehensive Plan of Care for R15, did include high risk for falls, and non-pharmacological interventions for behaviors. During an interview on 5/12/22 at 2:00 PM with the Physician's Assistant (PA) who wrote the order to increase the [MEDICATION(S)] from 12.5 milligrams to 25 milligrams, she stated, she was trying to control R15's behaviors and actions so that she did not get out of bed at night and stated that R15 gets scared at night. The PA stated she had been a PA for [AGE] years and had experience with geriatric patients, as well as worked in a family practice. The PA was asked about the approved indications for the use of [MEDICATION(S)], an antipsychotic, she stated she was aware of the uses for the medication [MEDICATION(S)]. The use is for [CONDITION(S)] and [CONDITION(S)] Disorder, but she was trying to keep R15 in bed at night. R15 does not have the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She did make the comment that R15 has [CONDITION(S)] and Hallucinations. No documentation could be found in the medical record to substantiate the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This surveyor brought to the attention of the PA that she documented in her follow-up visit for R15, after the fall on 4/10/22, dated 4/11/22, She is with her daughter who is requesting to have the [MEDICATION(S)] increased and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/13/22 at 9:14 AM with the facility Administrator concerning his expectations of residents receiving antipsychotic medications, he stated, We never want to restrain a resident. The facility is working closely with the provider for a gradual dose reduction. He went on to say that sometimes residents were admitted from the hospital with the antipsychotic medications. This surveyor asked for any education that the Personal Representative had received and signed, indicating that they were aware of the possible side effects of taking an antipsychotic medication. None was provided. Review on 5/13/22 at 10:00 AM of the facility policy titled, Antipsychotic Medication Use, states, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Under, Policy Interpretation and Implementation, Number 7. states, Antipsychotic medications shall generally be used for the following conditions/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], b. [CONDITION(S)] disorder, c. Schizophreniform disorder, d. delusional disorder, e. Mood disorders (e.g. [CONDITION(S)] disorder, depression with psychotic features, and treatment refractory major depression), f. [CONDITION(S)] in the absence of dementia, g. Medical illnesses with psychotic symptoms and or treatment-related [CONDITION(S)] or [CONDITION(S)], h. [CONDITION(S)] disorder, i. [CONDITION(S)], j. Hiccups (not induced by other medications), k. Nausea and vomiting associated with cancer or [CONDITION(S)]. Number 8. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to the above criteria, antipsychotic medications will only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others. Review on 5/13/22 at 11:00 AM of the, Product Monograph Including Patient Medication Information, for the antipsychotic medication, [MEDICATION(S)], states under number 3. Serious Warnings and Precautions Box: Serious Warnings and Precautions, Increased mortality in elderly patients with dementia. Elderly patients with dementia treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of thirteen placebo-controlled trials with various atypical antipsychotics (model duration of 10 weeks) in these patients showed a mean 1.6 fold increase in death rate in the drug related patients. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular, (e.g., heart failure, sudden death) or infections (e.g., pneumonia) in nature. The approved diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15 does not have documentation in her medical record as having either of these diagnoses.