Every finding on record at Sprenger Health Care of Port Royal

Based on review of facility policy, observation, interview, record review, pharmacy contract and manufacturer's package inserts (see USP (United States Pharmacopeia)), the facility failed to ensure that medications were safely stored at the correct manufacturer/USP temperatures in 1 of 1 automated dispensing cabinet.Findings include: Review of the facility policy titled Medication Storage Policy revised/reviewed 08/2021, stated, It is the policy of [NAME] Health Care Systems to ensure that all medications are maintained behind locked door that cannot be accessed by any unlicensed personnel. The Policy did not address additional aspects of medication storage. Review of the facility document titled, PHARMACY PRODUCTS AND SERVICES AGREEMENT dated 04/05/2018, revealed, Required Consultant Services . Consultant shall assist Facility in reviewing the safe and secure storage medications in locked compartments under proper temperature controls in accordance with manufacturers' specifications. Review of the USP storage conditions for pharmaceuticals revealed, primarily outlined in Chapters USP <659> <</and USP <1079><< defines precise temperature ranges to ensure stability: Controlled Room Temperature (CRT) (20 degrees C (centigrade) - 26 degrees C) (68 degrees F (Fahrenheit) - 77 degrees F. During an observation and interview on 03/10/2026 at approximately 10:50 AM, Registered Nurse (RN)1 led this Surveyor to the emergency drug supplies stored in an Omnicell automated dispensing cabinet (OADC), which was located on Hall 300, in the Data Storage Room (DSR). Upon opening the door to the DSR, RN1 stated it is always very hot in there and kept the door open. During an observation and interview on 03/10/2026 at approximately 10:52 AM, this Surveyor used a calibrated thermometer which indicated a temperature of 87.8 degrees Fahrenheit (F) inside the DSR. RN1 acknowledged the thermometer reading of 87.8 degrees F. The DSR door was closed by the Surveyor and the temperature was measured again by the Surveyor on 03/10/2026 at approximately 11:10 AM, using the same calibrated thermometer and the temperature inside the DSR was 86.2 F. During an interview on 03/10/2026 at approximately 11:12 AM, RN2 stated this room is always hot and was asked to contact the Maintenance Director (MD) to bring facility thermometer to the room. During an observation and interview on 03/10/2026 at approximately 11:20 AM, the MD used a laser thermometer to obtain temperature reading of 86.0 degrees F at 11:23 AM and 86.4 degrees F at 11:24 AM. The MD stated there was no air conditioning in the room and there was no thermometer in the DSR. Review of the [NAME] PORT ROYAL OMNICELL INVENTORY 1.30.2025 attached to the right side of the OADC, revealed the OADC contained approximately 173 medication line items and their associated quantities. This inventory included, but was not limited to multiple therapeutic classes of oral medications, injectable antibiotics, intravenous fluids, enoxaparin, epinephrine, inhalers, nasal spray, ophthalmic drops and ointments. During an interview on 03/10/2026 at approximately 12:30 PM, RN2 stated only Omnicare Pharmacy in [NAME] can provide a record of what/when/for whom a medication has been removed. On 03/10/2026 at approximately 1:35 PM, the Director of Nursing (DON) provided an Omnicell Transaction log from Omnicare of [NAME], dated 2/01/2026 - 3/10/2026. Subsequent review revealed approximately 79 transactions (removal of various medications) for multiple residents during this period. During an interview on 03/20/2026 at approximately 1:35 PM, the DON stated that a person from Omnicare of [NAME] comes periodically to resupply the OADC, but does not leave a report. On 03/20/2026 at approximately 1:48 PM, the DON provided copies of the Omnicare Medication Storage Audits since September 2025. Subsequent review of these audits failed to show that the OADC had been inspected by Omnicare of [NAME]. During an observation and interview on 03/11/2026 at approximately 2:15 PM, the Administrator and the DON accompanied this Surveyor to the DSR containing the OADC and both the Administrator and DON confirmed that the room was very warm, had no air conditioning outlet and that medications should be stored according to manufacturer's specifications. During an interview on 03/12/2026 at approximately 10:31 AM, the Consultant Pharmacist was unable to answer questions about Omnicare's practice related to Omnicare medication storage, stating that she would have to get in contact with the Omnicare General Manager.

Based on observation, interview, and review of facility policy, the facility failed to ensure food was labeled and stored appropriately in 1 of 1 kitchen.Findings include: Review of the facility policy titled Food and Storage Time Policy stated, . To maintain food quality and prevent foodborne illness, food should be stored for limited amount of time. During an observation and interview on 03/10/26 at 10:18 AM, with the Kitchen Manager, revealed the following items not dated/labeled/or stored appropriately: - 1 bottle of BBQ Sauce - labeled and dated, but in dry storage and should have been refrigerated after opening.- 1 bottle of Chives opened and not dated,- 1 bottle of baking soda opened and not dated. Observation of the Walk-In Cooler revealed:- 1 box of mushroom received on 02/12/26 with mold. Observation of the Main Kitchen, on a storage shelf revealed:- 2 bottles of Grape Jelly opened and dated, but in dry storage area and should have been refrigerated after opening.

Based on review of facility policy, observation, and interview, the facility failed to ensure in-room sharps containers were locked securely to prevent residents from accessing used sharps, needles, and syringes in 3 of 4 halls observed. Findings include:Review of the facility policy titled, Sharps Disposal Protocol with a date of 04/2022 revealed, Policy: It is the policy of [NAME] Health Care Systems to ensure that all sharps are properly disposed of after use . Protocol: . Staff will monitor the sharps containers .1. Review of R32's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, Parkinson's disease, dementia, anxiety, depression, difficulty in walking, repeated falls, and Type 2 diabetes. He was located in room [ROOM NUMBER] in the [NAME] Island Way hall, which was the locked memory-care unit.Review of R32's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/26, revealed R32 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated he had severe cognitive impairment. He was noted to have had physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others one to three days out of the seven-day look-back period. 2. Review of R49's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, dementia, major depressive disorder, encephalopathy (disorders that affect brain function), heart failure, and a history of falling. She was located in room [ROOM NUMBER] in the Dataw Island Way hall. Review of R49's admission MDS with an ARD of 02/16/26, revealed R49 had a BIMS score of 7 out of 15, which indicated she had severe cognitive impairment. 3. Review of R55's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) due to a stroke, anxiety, depression, seizures, viral infection, and muscle weakness. She was located in room [ROOM NUMBER] in the Hunting Island Way hall. Review of R55's admission MDS with an ARD of 02/10/26, revealed R55 had a BIMS score of 10 out of 15, which indicated she had moderate cognitive impairment. During an observation on 03/11/26 at approximately 10:00 AM, of R32's room (room [ROOM NUMBER]) revealed the sharps container on the wall was open. No lock was present in the door. The interior sharps box was approximately 1/4 full with used sharps, needles, and syringes. During an observation on 03/11/26 at 11:01 AM, of R55's room (room [ROOM NUMBER]) revealed the sharps container was open. A lock was present and in the locked position. However, the lock was not securing the door closed. The interior sharps box was approximately 1/4 full with used sharps, needles, and syringes. During an observation on 03/12/26 at 8:30 AM, of R55's room (room [ROOM NUMBER]) revealed the sharps container remained unlocked. The lock was present and in the locked position. However, the lock was not securing the door closed. During an observation on 03/12/26 at 8:50 AM, of R49's room (room [ROOM NUMBER]) revealed the sharps container was held closed by a piece of duct tape. No lock was present in the door of the container. During an interview on 03/11/26 at 10:52 AM, Housekeeper (HK)1 revealed, Housekeeping is responsible for changing out the sharps containers. We have a supply closet where we take them and switch them out with a new one. If the lock is broken, we are supposed to notify maintenance about it, so they can change the lock. I really haven't had to deal with that a lot. I think all the locks on this side are working.During an interview on 03/11/26 at 10:56 AM, HK2, outside of room [ROOM NUMBER], revealed, The lock is broken on that sharps container. I really don't know what to do in this situation. I will have to get back to you.During an interview on 03/11/26 at 11:01 AM, the Unit Manager (UM)1, while in room [ROOM NUMBER], verified the lock on the sharps container was not present and the sharps container was open. UM1 stated, I will remove the inner sharps box and notify maintenance that the container needs to be fixed.During an interview on 03/11/26 at 11:05 AM, HK1, while in room [ROOM NUMBER], verified the sharps container was open. She attempted to lock the sharps container, however, when she inserted her key, the lock would not rotate to the unlocked position to allow the cover to be closed. HK1 was not able to remove her key from the lock and stated, I will have to call maintenance to have them fix this.During an interview on 03/11/26 at 11:07 AM, the Administrator revealed, Our Housekeeping Director is not here today. You can talk to Maintenance Director (MD) in her absence.During an interview on 03/11/26 at 11:10 AM, the MD revealed, If the staff need anything, they put in a request. They can put it in TELS, but most of the time, they just tell me by word of mouth because I'm on the floor 95% of the time. No, I haven't received any requests to replace or fix the sharps containers in rooms 400 or 113. I did replace one in the 200 hall a few weeks ago, but I replaced that one because I noticed it was broken when I was in the room. I did not get a formal request to replace it. When I go in a room, I do a visual sweep of the room to see if there is anything I need to address while I'm there. Surveyor again asked the MD to confirm that he had not received any requests to fix or replace sharps containers in rooms [ROOM NUMBERS]. The MD stated, No, I didn't receive anything until just a few minutes ago.During an interview on 03/12/26 at 8:35 AM, the MD, while in room [ROOM NUMBER], verified the lock on the sharps container remained unlatched. He revealed, Yes, I know it is still not latched. I am just about to work on it now. See? I brought two sets of keys with me to try. I can put them in the lock, but they won't turn. I am getting ready to fix it now.During an interview on 03/12/26 at 11:00 AM, the Administrator revealed, Housekeeping is responsible for the sharps containers. If the sharps containers need to be fixed, the staff can put in a maintenance request in TELS. My expectation is that the staff put in those requests.

Based on observation, interview, record review, facility policy review and manufacturer product labeling, the facility failed to ensure that medications were dated when opened and stored at correct temperatures, once opened and further failed to ensure an outdated medication was removed from active storage for 1 of 2 medication rooms and 1 of 4 medication carts.Findings include: Review of the facility policy titled Medication Storage Policy, revised/reviewed 08/2021, stated It is the policy of [NAME] Health Care Systems to ensure that all medications are maintained behind locked door that cannot be accessed by any unlicensed personnel. The Policy did not address additional aspects of medication storage. During an observation on 03/10/2026 at approximately 10:32 AM, of the 400 Hall medication cart revealed the following:- 1 opened bottle of Trazodone 150 mg (milligram) VA (Veterans Administration) Rx (Prescription) #100281070D, belonging to Resident (R)13, on the left side in drawer 2, labeled by VA pharmacy Discard after 08/07/2025- 1 opened and in use container of [NAME] Ready Care Thickened Lemon-Flavored Water, sitting atop the medication cart at room temperature, labeled by the manufacturer good for 7 days after opening, store in refrigerator. During an interview on 03/10/2026 at approximately 10:41 AM, Registered Nurse (RN)1 verified both medication cart findings and stated that according to the [NAME] Thickened Lemon-Flavored water labeling, it should have been dated when opened and kept refrigerated. During an observation on 03/10/2026 at approximately 10:41 AM, of the Hall 400 medication refrigerator revealed the following:- 1 opened vial of Purified Protein Derivative (PPD), Aplisol 5 TU (test units)/0.1 ml (milliliter),1 ml (10 tests) multiple dose vial approximately 3/4 full, located inside the manufacturer's packaging box and dated as opened 1/1/2026 by the facility. The manufacturer label states, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During an interview on 03/10/2026 at approximately 10:45 AM, RN1 verified that the PPD had been dated 1/1/2026 when opened and was still in active storage in the refrigerator. During an interview on 03/11/2026 at approximately 2:15 PM, the Administrator and Director of Nursing stated that medications should be stored according to manufacturer's specifications and expired medications should not be left in active storage.

Based on a review of facility policy, resident records, and interviews, the facility failed to provide adequate supervision to prevent Resident (R)1 from eloping. Specifically, R1 had a successful elopement from the facility on 11/22/25. This failure to adequately supervise has the potential to cause serious injury or death to residents.On 11/25/25 at 6:57 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template informing the facility IJ existed as of 11/22/25. The IJ was related to 42 CFR 483.25 - Quality of Care.On 11/25/25 at 8:32 PM, the facility provided an acceptable IJ Removal Plan, indicating compliance as of 11/24/25. On 11/25/25 at 9:00 PM, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. It was determined the facility had put forth good faith attempts to identify and correct their own deficiencies as of 11/24/25. The IJ was identified at Past-Noncompliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.Review of the facility's policy titled, Person/Elopement, with a last revision date of 01/2022 revealed, To provide means by which to identify a resident who may be at risk to exit the facility unescorted, and to alert staff to the presence of these residents near facility exits through the use of engineering controls. For the purpose of this policy, an elopement will be identified as an unauthorized exit from the facility involving a resident whose cognitive status and safety awareness are impaired. 1. Nursing staff will assess a resident for risk for elopement on admission, or readmission. Social service and/or designee will reassess quarterly to coincide with the MDS and PRN. 2. Based on assessment, interdisciplinary team will develop and implement a comprehensive plan of care for risk of elopement. The care plan will be reviewed at a minimum quarterly and updated, as appropriate.Review of R1's face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, alcohol dependence, protein-calorie malnutrition, nausea with vomiting, alcohol use with withdrawal delirium, anxiety disorder, depression, liver disease, and spinal stenosis.Review of R1's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. Additionally, R1 had not exhibited any wandering behaviors, and no alarms or restraints were being used. Review of R1's Elopement Risk Assessment on 11/11/25 at 3:29 PM indicated R1 was disoriented to time, non-ambulatory, and not at risk for elopement due to being unable to elope at that time.Review of R1's Elopement Risk Assessment on 11/22/25 at 8:26 AM, after the elopement, revealed R1 was at high risk for elopement.Review of R1's Secured Unit/Willow Lane Screen on 11/22/25 at 11:09 AM after the elopement revealed R1 wanders or would wander out of the facility and would not be able to find his way back. Additionally, R1 was able to ambulate or was mobile in wheelchair.Review of R1's Care Plan revealed R1 had potential for impaired adjustment in new environment and with unfamiliar staff with a start date of 11/12/25. Approaches included assessing his interests and strengths and encouraging activity participation. On 11/24/25 after the elopement, the problem, Potential for Injury/ R1 is an Identified wanderer confusion, Desire to go home, was added. Approaches included knowing his whereabouts, attempting to divert, determining his pattern to wandering, reporting episodes, and having exit door alarms on. Additionally, R1 was to have a WanderGuard on at all times.Review of the progress note by Registered Nurse (RN)2 on 11/22/2025 at 12:45 PM (late entry) revealed, Pt sitting at the resident dining room this am, with no complaints. Vital signs taken, no behaviors observed at this time. Pt left dining area and search initiated, Manager on duty notified. Pt was found across the street at in the driveway of the store. Immediate intervention for safety after pt wandered off facility property, wander guard placed and pt re roomed to memory care room [ROOM NUMBER]. On call and family daughter notified.Review of the weather for 11/22/25 at 07:55 AM revealed the temperature outdoors was 65 degrees Fahrenheit in Port Royal, South Carolina.During an observation on 11/25/25 at approximately 12:00 PM, the road immediately outside the facility was a 2-lane road with a speed limit of 15 mph. The back of Dollar General faces the facility to the left.During an interview with the Maintenance Director on 11/25/25 at 2:10 PM revealed, I came in at 08:00 AM because I was the scheduled manager on duty. On those days, I have to come in for four hours. Usually when I first come in, I do my rounds. That day, I was starting my rounds, and I was told they were looking for R1. He typically sits in the 100/200 lounge, which they call the Ice Cream Parlor. He sits in a wheelchair. By the time I got to the front door, the Certified Nursing Assistant (CNA) was wheeling him back from Dollar General. He didn't seem any different. He looked the same. No, he didn't say what he was doing, and I didn't ask. I really don't know how it happened. What I suspect is he rolled his wheelchair close to the front doors, and they opened. The doors are automatic. Once he was back in the facility, RN2 called Licensed Practical Nurse (LPN)1, the nurse on call. I asked if they wanted to put a WanderGuard on him and was told yes. RN2 called the Point of Contact (POC) and got the ok to have R1 moved to the Memory Care unit. I gave the WanderGuard to the nurse. I would say the time lapse from the time they recognized he was missing to when he was found was about 20 minutes. I spoke with the son that day. He was a bit frustrated that R1 was moved. He said we didn't have written permission for that, but by that time, we had gotten verbal permission from his POC.During an interview with LPN1 on 11/25/25 at 2:30 PM revealed, I was the nurse on call the day R1 left the building. I was called by RN2, and she told me that R1 had left the building. I told her for safety we needed to transfer him to the Memory Care Unit, put a WanderGuard on him, and call the family. Yes, I did the assessments that day. I did them from home. I wasn't here in the building. On admission, R1 was pretty drowsy and out of it. Lately, he has been coming too. His wife visits him a lot. I don't remember him ever trying to leave the building before that incident. We will re-do the elopement assessment if there is a change, like what happened over this weekend, and when they are due. We get a trigger that tells us when they are due.During an interview with RN1 on 11/25/25 at 2:57 PM revealed, When R1 came in, he recently had been detox'd from alcohol. He was alert, maybe to 1-2. I was under the impression he was non-ambulatory. I know him from before him being here from out in the community. When I saw him the first day he was here, he had glassy eyes and no expression. He needed to be changed. About 2 days later, he was different. His eyes lit up when he saw me, and he was getting a little emotional. He seemed more aware of what was going on and where he was. What are the expectations about redoing nursing assessments? I don't want to answer it wrong. I'm not sure. Since he has been on the memory unit, he has gone to the door, but he is easily redirected. The residents you see outside? They are expected to sign out and in, so we know where they are. Nurse rounds and CNA rounds are how we keep track of the residents. We try to stay on the call lights. Actually, we try to do rounds early enough, so the resident doesn't have to use their light and doesn't go looking for what they need.During an interview with RN2 on 11/25/25 at 3:10 PM revealed, What I put in my note is exactly what happened. R1 was sitting in the lounge area about 45 minutes before he went missing. I was passing meds. I went into room [ROOM NUMBER] and gave the meds. Then, I went into room [ROOM NUMBER]. I came back out because the resident wanted the meds crushed. I remember seeing R1's orange [NAME] shirt, so I know he was there then. I was in that room for about 10-15 minutes. Prior to the incident, yes, he had shown wandering tendencies. He would roll around heading to the door. One day, he was rolling to the door saying he needed to take care of the tires. I was able to convince him his son was taking care of it, and he didn't need to worry about it. He would move from hall to hall. Over time, he had become more talkative and more aware. He was confused on and off. When the incident happened, I contacted the nurse on call and the manager on duty. We went room to room in the 100/200 Halls looking for R1. I went outside with the CNA. She went left, and I went right. She found him before I did. He had crossed the street and was part way up the curved part of the road leading to the Dollar Tree. The assessments are supposed to be done on admission and if there is an incident. Yes, an incident would be like what happened on Saturday.During an interview with CNA3 on 11/25/25 at 4:30 PM revealed, R1 kept trying to stand up and take his clothes off. I kept trying to redirect him. I went down the hall to answer a light for another resident, and when I was done about 15 minutes later, R1 was gone. We checked all the rooms and couldn't find him. I went outside and saw R1 across the street in the parking lot of Dollar General. I ran over to him and brought him back. He was not hurt at all. He was fine.During an interview with the Director of Nursing on 11/25/25 at 4:50 PM revealed, We do an elopement risk assessment the day admission. If a resident has a change, such as exit seeking, we would do another assessment. To prevent elopement, we get consent from a physician to put the resident on a secure unit. We also have WanderGuards. We get consent from family to put the resident on a secure unit. If family is not here, we obtain verbal consent with two nurses' signatures. I got a call on 11/22/25. The nurse last saw the resident at 07:55AM in the common area. The nurse went to administer medications to another resident. The nurse then went to pull R1's medications. When she went to the common area to look for him, he was not there. The nurse then activated a search for him, a code brown, which requires all staff to stop what they are doing and look for him. Staff searched all rooms on the skilled side. They then searched the premises and saw the resident sitting in his wheelchair in the parking lot of the Dollar General. Staff brought him back to the facility. The nurse did a physical assessment including a body audit. The nurse contacted the Nurse Practitioner, the nurse on call, the Director of Nursing, and the resident's daughter. The Maintenance Director was on campus, so he was able to obtain a WanderGuard. He activated the WanderGuard and gave it to the nurse to place it on the resident. The Maintenance Director then began helping the CNAs and nurses move the resident's belongings to memory care. I do not feel that any systems failed. In the midst of all of this, we got on a call to review what we had in place in the beginning, the current situation, and what interventions we put in place after to keep the situation from happening again.During an interview with R1's son on 11/25/25 at 5:20 PM revealed, I have a lot you should know. At 08:30 AM on Saturday morning, I got a call from my sister saying she got a call from RN2 saying they needed to move my dad to Memory Care for his safety. I got to the facility around 09:45 AM and ran into RN2. I wanted to talk to the manager on duty. He had already packed up my Dad's stuff in his room. I told him we never signed anything allowing the transfer of my Dad to the Memory Care unit, but it didn't matter. I was directed again to talk to someone else. When I saw my Dad in the Memory Care unit, he was bleeding down his arm. His arm was bruised, and he had 2 significant scrapes on his arms. The nurse said he had just fallen. So here, my Dad had just left the building unsupervised, and now, he falls for the umpteenth time . On 11/25/25, the facility provided a removal plan, which included:1. On 11/22/25 by approximately 6:00 P.M., DON conducted a whole house audit to ensure that elopement risk assessments were complete, and all at risk residents were in the secured unit, with wander guard orders. No concerns were noted.2. On 11/22/25 by approximately 6:00 P.M., DON/designee conducted a Whole house audit of elopement assessments completed and accuracy ensured. Any discrepancies corrected and appropriate parties notified. All notifications and any changes to plan of care to be documented. No concerns were noted.3. On 11/22/25 at approximately 6:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Regional Quality Assurance Nurse, Director of Clinical Services, Regional Administrator, COO, CEO, Executive Director of QA via telephone. The meeting discussed requirements of physician visits, elopement risk, notifications, communication, current orders, conditions, and corresponding policies.4. On 11/22/25 by approximately 8:30 P.M., the DON educated all Nursing staff on elopement policies and procedures, such as frequency of assessment, appropriate intervention (secured unit, wander guards), tools used to communicate any issues (elopement assessments, behavior charting, nurses' notes).5. On 11/22/25 by approximately 8:30 P.M., the DON completed education for all nurses on notification of change in condition policy and recognizing s/s of a change in condition.6. On 11/22/25 at approximately 8:45 P.M., Dr. [NAME], Medical Director, was notified of QAPI meeting discussion and the corrective action plan.7. On 11/24/25 by approximately 8:00 P.M., the Administrator and DON/ Regional Quality Assurance Nurse completed verbal education to all facility physicians and nurse practitioners regarding facility elopement policy and procedures, elopement risk, change of condition including elopement risk changes.8. Beginning on 11/24/25, the DON/designee would audit all admissions for elopement assessments, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly.9. Beginning on 11/24/25, the DON/designee would audit all nurses' notes for significant change and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly.10. Beginning on 11/24/25, the DON/designee would audit four residents elopement risk each week to check for any changes in elopement risk, if new risk identified, MD and RP notification completed, orders for secured unit and wander guard implemented as well as any needed follow up was completed for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to follow physician orders for 1 (Resident (R)9) of 2 residents reviewed for the provision of care and services. Findings included: A review of a facility policy titled, Incontinence Care Protocol, dated 03/2022, revealed, It is the policy of [facility] systems to outline the appropriate management for all residents with incontinence, to prevent the loss of skin integrity. A listed protocol directed staff to Apply moisture barrier cream and Assess/monitor skin with each incontinent episode. Review of an Admission Record indicated the facility admitted R9 on 06/07/2023 with diagnoses that included encephalopathy and prostate cancer. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/2023, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS noted R9 was frequently incontinent of urine and bowel. According to the MDS, the resident did not have any wounds or skin conditions. Review of Resident #9's Care Plan, initiated on 06/07/2023, revealed R9 had a potential for impairment of skin integrity. The Care Plan directed staff to apply moisture barrier after each incontinent episode. A review of the label for Calmoseptine ointment revealed, Uses: A moisture barrier that prevents and helps heal skin irritations from: urine. A review of R9's Kardex Report, dated 06/07/2023, revealed, Skin Preventative. Moisture barrier after each incontinent episode. On 09/30/2023 at 10:25 AM, Certified Nursing Assistant (CNA)10 was observed providing incontinence care for R9. CNA10 properly explained to the resident what she needed to do and the resident provided permission for the surveyor to observe the care being provided. R9's existing incontinence brief was removed and was observed to be wet, but not soaked. R9 was cleaned using wet wipes and a clean incontinence brief was placed on the resident. R9's skin was observed to be clean, dry, and without any breakdown or redness. There was no application of a barrier cream. During an interview on 09/30/2023 at 10:30 AM, CNA10 stated the facility used Calmoseptine as a barrier cream, noting it was used whenever the aides noticed redness on a resident's buttocks or groin area. CNA10 stated if Calmoseptine was used, a nurse was notified. During an interview on 09/30/2023 at 10:35 AM, Licensed Practical Nurse (LPN)13 stated the facility used Calmoseptine as a barrier cream, noting a corresponding order would be on the treatment administration record (TAR). LPN13 noted that, if he or the aides noticed redness or breakdown, he contacted the nurse on call to obtain a treatment order. LPN13 stated there was always a nurse on call. LPN13 identified that the aides obtained barrier cream from a nurse to apply. During an interview on 09/30/2023 at 12:25 PM, R9 stated the nurses kept them clean and dry, though the resident was unable to endorse if staff applied cream during incontinence care. R9 noted there were no issues with their skin or timely incontinence brief changes. During an interview on 09/30/2023 at 12:30 PM, CNA10 stated she did not apply barrier cream to Resident #9 during the observation of incontinence care, noting their skin was not red. CNA10 opened a Kardex (a list of care instructions in the electronic medical record,) which revealed Resident #9 was to receive barrier cream following every incontinence episode. CNA10 then stated she had not applied the barrier cream as she had ran out, and did not have anyone to get it for her, as the nurses were all agency and did not have a key to get into the storage area. On 09/30/2023 at 12:50 PM, the Director of Nursing (DON) accompanied the surveyor to the storeroom, noting that, while the storeroom was accessible by all staff, the Calmoseptine cream was not located in the storeroom. The DON stated barrier cream was stored in the treatment cart, noting all nurses had a master key and were able to obtain the cream whenever requested by an aide. During an interview on 09/30/2023 at 4:00 PM, CNA15 stated barrier cream was applied following every changing, which was noted on the Kardex. The CNA stated barrier cream was obtained from a nurse, stating the aides generally knew who needed barrier cream, which they obtained prior to entering the resident's room. During an interview on 09/30/2023 at 4:15 PM, the DON stated CNAs were required to apply barrier cream after each incontinence episode for all incontinent residents, noting that while this was not documented in the plan of care, the nurses charted the barrier cream application on the resident's TAR once alerted by the CNA. The DON stated CNA10 should have applied a barrier cream to R9's perineal area after providing incontinence care, noting there was no reason not to. A review of CNA10's Nurse Aide Competency Evaluation, dated 11/28/2022, revealed the CNA received education and provided a return demonstration for incontinence care and review of the Kardex as it pertained to the prevention of skin breakdown. During an interview on 09/30/2023 at 4:30 PM, the Administrator was made aware of the concern and stated he expected the aides to apply barrier cream following each incontinence episode.

Based on observation, interview and facility policy review, the facility failed to provide safe and effective medication administration by allowing expired medications to be available for resident use in two (2) of two (2) medication storage rooms. Findings include: The facility provided policy titled Medication Storage Guidance dated 2021 directed, [MEDICATION(S)] Tests: [MEDICATION(S)] Injection: [MEDICATION(S)] Injection. Store in the refrigerator at 36 degrees to 46 degrees F [Fahrenheit] (two (2) degrees to eight (8) degrees C [Celsius]). Protect from light. Do not freeze. Date when opened and discard unused portion after 30 days. Observation of the Front Medication Room on 8/18/21 at 12:20 p.m. with Licensed Practical Nurse (LPN) #2 revealed one (1)multi-dose bottle of [MEDICATION(S)] [CONDITION(S)] skin testing solution for resident use in a box dated 7/6/21. During interview with LPN #2 at that time, s/he stated nurses should date the bottle when opened and discard it after being open for 30 days. LPN #2 stated it appeared there was at least one (1) dose left in the bottle, and it was expired. LPN #2 stated the Unit Manager checked the expiration dates of the medications, and each nurse should check the expiration date before giving the medication/solution to a resident. Observation of the Back Medication Room on 8/18/21 at 12:45 p.m. with LPN #2 revealed two (2) multi-dose bottles of [MEDICATION(S)] [CONDITION(S)] skin testing solution for resident use in one (1) box dated 7/13/21. LPN #2 stated s/he would discard both bottles of the [MEDICATION(S)] because the only date was 7/13/21 and was expired 30 days after the open date. LPN #2 stated there were several doses remaining in each opened bottle. During an interview on 8/18/21 at 2:16 p.m., the Director of Nursing (DON) stated his/her expectation was the open date should be written on the medication, ideally on the bottle instead of the box. The nurse should check for the date opened before giving the medication, and the bottle should be discarded after 30 days. During an interview on 8/20/21 at 8:53 a.m., the Pharmacist stated for [MEDICATION(S)] used after 30 days post opening, the potency of the solution may not be as effective. The Pharmacist stated a medication room audit was done monthly and any irregularities or expired medications were reported to nursing staff.

Based on staff interviews, resident interviews, observations and review of the South Carolina Department of Health and Environmental Control (DHEC) guidelines, the facility failed to conduct a risk assessment for 1 (Resident 1) of 2 [MEDICAL TREATMENT] residents who frequently left the facility for treatments, and for 1 (Resident 2) of 1 resident reviewed who was treated in the emergency room , to determine the appropriate transmission based precautions required by the staff. This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. The census was 29. The findings included: 1. According to DHEC, Managing the Flow of Residents - Cohorting During COVID Times, dated 07/20/20, [MEDICAL TREATMENT] residents should be placed, Ideally in a private room with bathroom on the negative unit. If this is not feasible, a risk assessment should be performed to determine most suitable option. A risk assessment example given by DHEC included, in part, - How frequently does the resident require [MEDICAL TREATMENT]? - What is the number of service providers, including transportation, that the resident comes in contact with? The greater the number of contacts, the greater the risk of transmission. - Review of the service provider's policies on COVID-19 and cohorting. - Has education been provided/could it be provided to the resident? Such as encouraging hand hygiene, wearing a mask, social distancing from other patients. - What are the service provider practices for reducing transmission of COVID-19?Resident 1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of Resident 1's care plan did not show an identified risk of exposure to COVID-19 while out for [MEDICAL TREATMENT] treatments. On 09/16/20 at 8:35 AM, an interview was completed with the facility Administrator and Director of Nurses (DON). The DON reported that residents who were not on any kind of isolation, and left the facility for any type of medical treatment, were returned to their rooms on the non-isolation unit. The DON also said that Resident 1's most recent [MEDICAL TREATMENT] treatment was on 09/15/20. The DON verified that Resident 1 was not in an isolation room.On 09/16/20 at 2:33 PM, an interview was completed with Resident 1. Resident 1 stated that there were usually 10 other patients receiving [MEDICAL TREATMENT] at the time he was there. Resident 1 also stated that last week, he waited two hours in the lobby of the [MEDICAL TREATMENT] center waiting for transportation back to the facility. A follow up interview was completed with the DON on 09/16/20 at 11:52 AM. The DON said that no risk assessments were completed for residents who leave the facility to determine the appropriate placement on return. 2. Review of Resident 2's nurse progress notes revealed that after a fall, Resident 2 was sent to the emergency roiagnom on [DATE] at 12:28 PM. The Director of Nurses (DON) reported that Resident 2 returned to the facility on [DATE], but there was no documentation to verify the date or time of the return. On 09/16/20 at 8:35 AM, an interview was completed with the facility Administrator and DON. The DON reported that residents who were not on any kind of isolation and left the facility for any type of medical treatment, were returned to their rooms on the non-isolation unit. The DON verified that Resident 2 was not placed in an isolation room upon return from the emergency room . Resident 2 was no longer at the facility at the time of the survey. A follow up interview was completed with the DON on 09/16/20 at 11:52 AM. The DON said that no risk assessments were completed for residents who leave the facility to determine the appropriate placement on return.

Based on staff interview, the facility failed to employ an Infection Preventionist who had completed specialized training in infection prevention and control. This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. The census was 29. The findings included: On 09/16/20 at 8:35 AM, an interview was completed with the facility Administrator and the Director of Nurses (DON). The Administrator and DON identified the DON as the facility's Infection Preventionist. A follow up interview was completed with the DON on 09/16/20 at 11:52 AM. The DON stated she had registered to take the Centers for Disease Control (CDC) certification class for Infection Preventionists, but had not started it yet, and had not completed any other specialized training.

Based on staff interview, the facility failed to develop a process for notifying residents and residents' representatives each time a confirmed COVID-19 test result was identified or to provide weekly COVID-19 updates for 29 of 29 residents. This deficient practice occurred during the COVID-19 pandemic. The census was 29. The findings included: A review of the COVID-19 test results revealed the most recent date a resident tested positive was on 08/31/20, and the most recent date a staff member tested positive was on 09/01/20. The facility Administrator provided all written notices that were sent to family members from 08/01/20 to 09/16/20. Notices provided were dated 09/04/20, 09/10/20 and 09/15/20. The Administrator verified that no other written notices had been sent. On 09/16/20 at 1:55 PM, an interview was completed with the facility Administrator. The Administrator stated that he sent out emails to residents' families to update them on COVID-19 and that Life Enrichment Manager (LE) 2 spoke to residents to update them. An interview was completed with LE 2 on 09/16/20 at 2:15 PM. LE 2 stated she had made calls to some families to update them on COVID-19 cases, but had not been asked, and had not spoken to any residents. A follow up interview was completed with the Administrator on 09/16/20 at 2:24 PM. The Administrator said he could not remember who had been asked to speak with residents about COVID-19 cases and acknowledged that there was no documentation to show it had been done.

Based on interviews and document review, the facility failed to ensure the staff acknowledged and acted promptly upon the grievances voiced by the Resident Council related to the staffs' slow response time to call lights as indicated by 10 of 10 residents in attendance during the Resident Council Interview (Residents (R)1, R3, R4, R5, R6, R7, R8, R10, R11, and R15). The findings included: Review of the monthly Resident Council Meeting Minutes dated 12/20/18 through 08/28/19 revealed the following statements of concern regarding the issue of the Certified Nursing Assistants (CNAs) not answering the residents' call lights in a timely manner: On 12/20/18 - Two complaints of the CNA taking too long to answer the call button. On 01/30/19 - A couple of complaints about how long it takes the CNAs to answer the call button, especially at night. On 03/27/19 - A few residents say it takes too long for call buttons to be answered. On 04/30/19 - Complaints about call button not being answered. On 06/26/19 - Complained of CNAs and (the) RN (Registered Nurse) on night shift taking too long to answer the call button. On 07/31/19 - One resident said she rang her call button at 4:50 AM and it was 6:30 AM before anyone came to help her. She had needed to go to the restroom and soiled herself while waiting. One resident said she waited an hour and a half for someone to put her on the bedpan and another hour to get off when she finished. One resident has a family member stay every night because the CNAs do not answer the call buttons in a timely manner. On 08/28/19 - Residents continued to express concern about night time aides and how long it takes for their call buttons to be answered. During the Resident Council Interview held on 09/18/19 at 10:30 AM, the 10 residents that attended the meeting indicated additional facility staff is needed during the night shift to ensure residents call lights are answered in a timely manner by the staff. The residents did not remember ever receiving an update regarding any concerns they voiced to the administration in the past. Review of four Resident Council Meeting Follow Up Concern Form(s), completed by the Life Enrichment Director (LED) on 03/27/19, 04/30/19, 06/26/19, and 08/28/19 revealed all four forms addressed the residents' complaints of the CNAs not answering the call lights in a timely manner. The section of the forms to be completed by the department manager explaining the department manager's follow up or correction of the complaint was left blank on all four forms. During an interview on 09/19/19 at 9:30 AM, the LED stated the majority of the meeting minutes did not have an attendance roster due to the lack of residents attending the group meeting. The LED stated since the majority of the residents, . will not come out of their rooms for a Resident Council Meeting, she began going from resident room to resident room in order to ask the residents about complaints or needs they may have. The LED stated she did not keep a list of the residents she spoke with on these room visits. The LED explained her process regarding concerns shared at Resident Council Meeting was to complete the Resident Council Meeting Follow Up Concern Form and provide the form to the department manager over the area of concern, in these cases, the Director of Nursing (DON). The LED stated the concern forms are also forwarded to Corporate Quality Assurance Director (CQA). The LED stated she has never received a resolution from anyone regarding the CNAs slow response to answering call lights. The LED stated she was not aware of a written policy or procedure regarding a process to address concerns stated by residents at a Resident Council Meeting. During an interview on 09/19/19 at 11:00 AM, the CQA stated there was no documented follow up or corrective actions for the Resident Council Meeting Follow Up Concern Form documents completed on 03/27/19, 04/30/19, 06/26/19, and 08/28/19. The CQA did not know why the DON had not taken any actions to correct the CNAs slow response times to call lights.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered program of activities and associated care plan designed to meet the recreational interests and socialization needs for one resident on contact isolation precautions out of 16 residents selected for review (Resident (R)2). The findings included: Review of R2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An admission to the hospital occurred on 08/24/19 due to an abdominal wall abscess resulting in an additional abdominal surgery. R2 returned to the facility on [DATE] with orders for wound care for her abdominal incision, orders for physical and occupational therapy, and orders for contact isolation precautions due to a new [DIAGNOSES REDACTED]. diff) toxin infection (a communicable infection of the intestines). Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated she had no cognitive impairment. The MDS assessment indicated it was somewhat important to the resident that she be able to, go outside to get fresh air when the weather is good and to participate in religious services or practices. During an interview on 09/16/19 at 11:00 AM, R2 stated her desire to get stronger so she could return home. R2 was aware that she was on contact isolation precautions due to her infection and that she had to stay confined to her room. R2 stated the physical and occupational therapists come to her room to provide therapy, and when she was not busy with therapy, she worked on her word puzzle book on her bedside table. During a subsequent interview on 09/17/19 at 10:30 AM, when asked if a staff member had offered her activities that she could do in her room, R2 stated, No, and then added that she was interested in receiving additional activities because she did not enjoy watching television all day and only had a word puzzle book for entertainment. Observation of the resident's room revealed the room was devoid of activity materials/items except for a television and the resident's word puzzle book. During an interview on 09/19/19 at 9:30 AM, the Life Enrichment Director (LED) reviewed R2's record and stated that she could not find any care plan documentation that addressed specialized activities to meet R2's recreational needs. The LED stated that the activity department had activities available for residents who are unable to leave their room; however, the LED could not produce an activity care plan for R2. The LED stated the staff from the activities department visit with R2 three times a day; however, she had no documentation of these activities being provided. The LED stated that per her assessment of R2, the resident enjoyed crafts, and added that the life enrichment staff could do crafts with R2 in her room. The LED stated that she was not aware of a facility policy that addressed these topics.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure staff used standard precautions to prevent the potential spread of infection during the preparation and administration of medications for two of six residents observed during medication pass (Residents (R)5 and R18). The findings included: 1. Observation on 09/18/19 at 7:42 AM revealed Registered Nurse (RN)1 used an alcohol-based hand rub to cleanse her hands. Using her bare hands, the RN then picked up a potentially contaminated bottle of medication for R5 and dispensed two tablets from the medication bottle into her ungloved right hand. The RN then placed the tablets in a medication cup, and proceeded to administer the medication to R5. 2. Observation on 09/18/19 at 8:11 AM revealed RN1 used an alcohol-based hand rub to cleanse her hands. Using her bare hands, the RN then picked up a potentially contaminated bottle of medication for R18, dispensed one tablet from medication bottle into her ungloved right hand and placed the tablet in a medication cup. RN1 then popped out two tablets from two potentially contaminated medication blister packs into her ungloved right hand and then placed these two tablets into the medication cup. Continued observation revealed RN1 then went into R18's room and handed the resident the medication cup. When R18 dropped one of the tablets onto the bed linen, RN1 picked up the tablet with her ungloved hand and gave it back to the resident to take. During an interview on 09/18/19 at 8:20 AM, when asked about the appropriate method for medication administration, RN1 stated, Medication should be placed directly in medication cup, and not be handled by bare hands. RN1 then stated, I should have disposed of the pills once I touched them. During an interview on 09/18/19 at 8:45 AM, when asked about the correct process for dispensing residents' medications, Licensed Practical Nurse (LPN)1 responded, If the resident's medications are in liquid or in pill form, it is placed directly in the medication cup prior to administration. (if touched or dropped), the medication has to be disposed of and replaced prior to giving it to the resident. During an interview on 09/18/19 at 8:51 AM, when asked about the orientation and training process for the nursing staff related to medication administration and dispensing of medications, the Director of Nursing (DON) responded, The nurses are given a six-week orientation on (medication) cart training with oversight. The DON then stated, The medication pass is a clean process, do not touch the medications or the top rim of the medication cup. The nurse should never handle medications bare-handed, and if they do, it (the medication) should be wasted (disposed of). Review of the facility's policy titled, Medication Administration, revised 07/2013, indicated: . medication is administered in a safe manner . Medication is prepared and administered using good technique. Further review of the policy revealed it did not provide guidance or examples of what was considered good technique for medication administration, nor did the policy specify the source or professionally-accepted guidelines used in the development of the medication administration policy.

Based on observation, interview, and record review, the facility failed to ensure the staff used a gait belt to transfer one of eight sampled residents (Resident (R) 7). Findings include: Review of an undated Nurse and State tested Nursing Assistant (STNA) training document indicated: Every resident will have a required method for all transfers- refer to (the) Kardex for details. Do not lift (a resident) from under (their) arm pits, pull up on (their) arms, (or) bear hug (a) resident to move them. Review of R7's admission documentation indicated the facility admitted the resident on 05/25/18 with [DIAGNOSES REDACTED]. Review of R7's Nursing Admission Assessment, dated 05/25/18, indicated R7 was, Able to sit in wheelchair. Requires total assist with all ADLs. Review of the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 06/01/18 specified under Section C: Cognitive Patterns, that R7 had a Brief Interview for Mental Status (BIMS) score of one out of 15, which indicated he had severe cognitive impairment. Section G: Functional Status, indicated R7 required total assistance of two or more persons for transfers. Review of R7's undated care plans indicated the staff developed a Focus statement that read: ADLs (Activities of Daily Living) self-care deficit R/T (related to) [MEDICAL CONDITION], major [MEDICAL CONDITION] and OA ([MEDICAL CONDITION]). Interventions included, Transfers -two person assist for safety. Review of a hospice note, dated 07/20/18, indicated the resident had begun to exhibit, Contracture(s) of arms and legs. arms and legs drawn up in fetal position. Will not straighten without assist. Observation on 08/28/18 at 8:15 AM in R7's room revealed Certified Nurse Aide (CNA)1 used the call light to request assistance, and then moved the resident's Broda chair next to his bed. CNA1 stated, I do not transfer him alone, he needs two people to assist in transfer. Continued observation revealed Registered Nurse (RN)1 arrived to assist the CNA to transfer R7. CNA1 and RN1 approached the resident, and without applying a gait belt (an assistive device belt made of heavy canvas or nylon that is placed around a resident's waist and allows the staff to grasp the belt to assist in lifting or moving a person) around the resident, transferred R7 to his chair by pulling on his arms and sweatpants to lift and pivot him to the chair. The resident cried out and grimaced during the transfer. Once in his Broda chair, the CNA and RN repositioned R7 by again using his arms, which also caused the resident to grimace. Neither CNA1 nor RN1 had a gait belt with them to use in transferring the resident. Observation and interview on 08/28/18 beginning at 1:46 PM revealed CNA2 and CNA3 prepared to transfer R7 from his Broda chair to his bed. Both CNAs wore gait belts around their waists; however, neither CNA applied their gait belt around the resident prior to the transfer. The CNAs each placed a hand under the resident's arms and with the other hand, grasped the resident's sweatpants to stand and pivot the resident to the bed. During an interview, CNA2 stated the staff have had a lot of in-service training, which included proper lifting. CNA3 stated that R7 sometimes yells during care. The CNA stated, His yelling is just a habit, it is just the way he is. He cried out today but did not yell like he usually does. CNA3 stated she had been trained on proper transfers. During an interview on 08/28/18 at 11:25 AM, the Administrator stated the facility did not have a specific transfer policy; the staff follow therapy recommendations on transfers. During an interview on 08/28/18 at 2:13 PM, the Director of Rehab stated every staff member that works with residents should have a gait belt and be trained in its use. The Director of Rehab stated a gait belt should be wrapped snuggly around the resident's waist, but not be uncomfortable. A gait belt helps the staff to have better control when assisting the residents and eliminates pulling on the resident's body. The Director of Rehab stated the risks of pulling on a resident's underarms during transfers includes potential injuries to the resident's shoulder, muscles, and nerves under the arm. The Director of Rehab stated the facility provides gait belts the nursing staff, otherwise he has a box of them in the therapy office available for staff. During an interview on 08/28/18 at 2:35 PM, the Director of Nursing stated the staff are to follow the facility policy, use a gait belt, and not lift resident's under their arms.