Saluda Nursing Center

In the surveyor’s words

From the most serious findings on record at Saluda Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Apr 17, 2025

  Based on record review, interview, and policy review, the facility failed to ensure that code status was reflected accurately in the medical record for one of 11 residents (Resident (R) 360) reviewed for advanced directives of 36 sample residents. R360 requested to be a Do Not Resuscitate (DNR) but was listed as a Full code in the electronic medical records and hard chart. The facility's Administrator was informed on 04/16/25 at 3:20 PM that Immediate Jeopardy existed related to the failure to ensure that one of 11 residents identified as requesting to be a DNR, was documented as DNR. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 04/17/25 at 4:14 PM. […]

• Immediate jeopardy, isolatedF678Apr 17, 2025

  Based on record review, interview, and policy review, the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated after one of 11 residents (Resident (R) 361) was found unresponsive on [DATE]. The facility's Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were informed on [DATE] at 6:18 PM that Immediate Jeopardy (IJ) existed related to the failure to ensure that one of 11 residents received CPR as required. The facility provided an IJ Removal Plan that was accepted on [DATE] at 4:37 PM. The survey team validated implementation of the removal plan through interviews, and review of training records. IJ was verfied as removed on [DATE] at 5:21 PM, with a compliance date of [DATE]. […]

• Immediate jeopardy, isolatedF600May 30, 2023

  Based on record review and interviews, the facility failed to prevent neglect to Resident (R)8, who was diagnosed with Vascular Dementia and history of wandering. Specifically, on 05/16/23 at 6:34 PM, R8 successfully eloped from the facility. R8 eloped through the front sliding doors of the facility by following closely behind an unidentified individual. R8 was observed by two other cognitively intact residents (R10 and R11) wandering outside of the building and going towards a local doctors office. R10 notified nursing staff that R8 was outside wandering without supervision and was brought back to the facility by staff. […]

• Immediate jeopardy, isolatedF689May 30, 2023

  Based on record review, interviews, and video surveillance, the facility failed to ensure proper supervision of Resident (R)8, who was diagnosed with Vascular Dementia and history of wandering. Specifically, on 5/16/23 at 6:34 PM R8 successfully eloped from the facility. R8 was observed by two other cognitively intact residents (R10 and R11) wandering outside of the building and going towards a local doctor's office. R10 notified nursing staff that R8 was outside wandering without supervision and was brought back to the facility by staff. On 5/30/23 at 1:45 PM the Administrator and the Director of Nursing (DON) were notified that R8's successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. […]

• No harm, potential for more than minimal, widespreadF812Jun 18, 2026

  Based on observation, interview, and facility guideline review, the facility failed to date, label, and/or cover food products stored in 1 of 1 kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 142 of 144 residents who consumed food prepared from the facility's kitchen.Findings include: Review of the facility's undated and untitled guidelines that the facility followed for food storage and provided by the Dietary Manager (DM), revealed a content list for storing staples, refrigerator, freezer items, mixes, and packaged foods. The document addressed storage and handling by food category. […]