Johns Island Post Acute

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to check vital signs (VS) for Resident (R)1 and R2, according to the physician's order, for 2 of 3 residents reviewed.

Inspectors wroteBased on observation, facility policy review, record review, and interview, the facility failed to ensure proper infection control measures were followed for Resident (R)4, for 1 of 1 resident reviewed on Contact Precautions.

Inspectors wroteBased on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)5 from physical abuse by R4. Specifically, on [DATE] at approximately 4:43 AM, R4, while in a wheelchair, rolled behind R5 placed his arm around R5's neck and began to choke R5. Certified Nursing Assistant (CNA)1, who witnessed the incident, separated both residents. Furthermore, the facility neglected to provide care and services to R5, following the physical altercation. Specifically, the altercation occurred on [DATE] at approximately 4:43 AM, R5 was placed in his room at approximately 5:03 AM. R5 was found in his room unresponsive and with no pulse at approximately 7:35 AM. During this time frame, the facility failed to assess R5, failed to conduct a body audit of R5, and failed to follow up with R5, after the physical altercation. [...]

Inspectors wroteBased on review of facility policy, record review, interviews, and review of video footage, the facility failed to provide appropriate care for Resident (R)5, who had a respiratory care plan and physician orders, after the resident was choked by another resident on [DATE]. Additionally, the facility failed to provide wound care according to professional standards of practice for R8. On [DATE] at 5:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Quality of Care. On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team, validated the facility's corrective actions and removed the IJ. [...]

Inspectors wroteBased on review of the facility's policies, document review, and interviews, the facility failed to ensure all staff, to include agency staff, received orientation, training, and in-services on facility policies and procedures, prior to working with residents. Specifically, the facility had agency staff working as a charge nurse, floor nurse, and aide without the proper training. This deficient practice had the potential to effect all residents in the facility.

Inspectors wroteBased on a review of the facility policy, observations, interviews, and record review, the facility failed to ensure that self administration of medications was clinically appropriate as required for Resident (R)8, 1 of 1 resident reviewed for self administration. Two medications, a nasal spray and an albuterol inhaler, were found at R8's bedside without an assessment or authorization for self administration. This failure placed the resident at risk for medication errors and adverse health outcomes. Findings Include: Review of the facility policy titled Self Administration of Medications, last revised February 2012, states: Residents have the right to self administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. [...]

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to report to the State Agency (SA), two incidents of resident to resident phsyical abuse, in a timely manner. For 2 of 3 residents reviewed.(Cross Reference F600)

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to thoroughly investigate an incident of resident to resident physical abuse involving Resident (R)4 and R5, for 1 or 3 residents reviewed.(Cross Reference F600 and F726)

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to create a Comprehensive Person Centered Care plan for Resident (R)4, related to his aggressive behaviors and R8 related to self administration, for 2 of 3 residents reviewed for Care Plans.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure the comprehensive care plan was updated and revised to reflect changes in condition and care needs for 1 of 2 residents (R8) reviewed for care plans. The care plan was not updated when R8's peripherally inserted central catheter (PICC) line was removed, and it did not include interventions related to self administration of medications. This failure created the potential for unmet needs and inconsistent care. Findings Include: Review of the facility policy titled, Care Plans - Comprehensive with a revised date of September 2010, documented, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: [...]

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure the accurate transcription of physician orders for 1 of 2 resident (R8) reviewed. R8's wound care order was entered incorrectly on the Medication Administration Record (MAR) as daily, while the Physician's instruction required treatment every other day (QOD). This failure created the potential for incorrect treatment frequency and adverse outcomes. Findings Include:Review of the facility policy titled Medication Orders, last revised November 2014, states Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident . Recording Orders .6. [...]

Inspectors wroteBased on review of the facility policy, observations, interviews, and record review, the facility failed to maintain appropriate infection prevention and control practices during wound care for 1 of 1 residents reviewed for wound care, Resident R (8). This failure had the potential to expose the resident to cross contamination, delayed wound healing, and increased risk of infection, including the possibility of developing a preventable wound infection or worsening of the existing wound. Findings Include: Review of the facility policy titled, Enhanced Barrier Precautions, last revised December 2024, states, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. Enhanced barrier precautions apply when . b. [...]

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)137 was discharged from the facility to a safe environment. Per a phone interview with R137 and the Local Ombudsman, R137 revealed he was discharged from the facility on 01/22/26 to a home without utilities (water/electricity). R137 indicated this failure has caused his health to decline due to lack of adequate Durable Medical Equipment (DME-devices and supplies that are intended for repeated use and are essential for managing health conditions at home) and appropriate community services (Home Health), for 1 of 2 residents, reviewed for discharge. [...]

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure medications and biologicals were not expired, were properly stored, and were properly maintained for four (4) of six (6) medication carts reviewed and one (1) of one (1) wound care supply closet. Findings Include:Review of the facility policy titled, Storage of Medications last revised November 2020 revealed Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Observations conducted on 02/23/26 and 02/24/26 of medication storage areas revealed there was one (1) wound care supply closet and three (3) units: Angel Oak Unit, [NAME] Unit, and [NAME] Unit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to prevent a sheering injury for Resident (R)133, for 1 of 2 residents reviewed for quality of care. Findings Include:Review of R133's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, aftercare following joint replacement surgery, presence of right artificial hip, systemic lupus erythematosus, Sjogren syndrome, mild intellectual disabilities, depression and urinary tract infection. Review of R133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/26 revealed R133 is dependent with toileting hygiene and personal hygiene. Review of R133's Brief Interview of Mental Status (BIMS) performed on 02/20/26 revealed a score of 12 of 15, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on review of the facility policy, record review, observations, and interviews, the facility failed to follow the infection control policy by providing hand hygiene and usage of gloves, while providing resident care for Resident (R) 69. This failure had the potential to place R69 at risk for infection for the improper use of gloves while providing catheter care, for 1 of 4 residents reviewed for infection control.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was free from neglect. Specifically, R1 did not receive care and services, to address the residents therapeutic diet, resulting in R1 expiring. For 1 of 1 resident reviewed for neglect. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide care and services to a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F600. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. The IJ was related to 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. On 10/23/24 at 6:20 PM, the facility presented an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was adequately supervised and free from accident and hazards, for 1 of 1 residents reviewed for accidents. Specifically, R1, who was on a therapeutic diet, consumed food from another resident's meal tray that was left on a dining room table, resulting in R1 expiring. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide adequate supervision of a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F689. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. The IJ was related to 42 CFR 483.25 Quality of Life. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure eight of nine residents and their representatives (Resident (R) 22, R26, R42, R56, R94, R106, R111, R112 and R113) reviewed for facility initiated emergent hospital transfer from a total sample of 28 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Additionally, the Ombudsman was not notified of hospital transfers for R22, R42, R94, R112, and R113.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to recognize and thoroughly investigate an injury of unknown origin for one of 28 sampled residents (Resident (R)52). This had the potential to cause residents to be at risk of abuse when injuries of unknown origin were not fully investigated.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R) 13) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment, planning for resident care, and potentially affect post facility care of the resident.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the care plan regarding resuscitation was updated for one of one resident (Resident (R) 111) out of 28 residents reviewed. The failure to keep a care plan current could affect the appropriateness of care provided in the case of a respiratory or cardiac arrest.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide restorative nursing services to one of one resident (Resident (R) 112) reviewed for restorative nursing services out of a total sample of 28. This had the potential for increased contractures and a decrease in mobility.

Inspectors wroteBased on review of the facility's policy, record review, observation, and interviews, the facility failed to promote the dignity of a resident who was observed with staff standing while assisting the resident to eat a meal for 1 Resident (R)118, of 1 resident reviewed for dignity.