Palmetto Subacute Care Center

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to provide oxygen therapy at the rate ordered for one (Resident #104) out of one resident reviewed for respiratory therapy as evidenced by Resident #104 was receiving oxygen at a flow rate of 3.5 liters per minute instead of the physician-ordered 2 liters per minute as needed. This deficient practice has the potential for increased significant health risks including oxygen toxicity and pulmonary damage.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide safe and secure storage of medications and biologicals for five Residents (Resident #6, Resident #9, Resident #31, Resident #32 and Resident #102) out of 18 residents sampled. There were 88 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F761-Label/Store Drugs and Biologicals. As evidenced by: F761 was cited during a Recertification Survey with exit dated 12/19/24 because the facility failed to ensure drugs and biologicals used in the facility were stored and labeled properly.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate storage of personal cleaning supplies for one Resident (#101) out of 18 sampled residents. As evidenced by dishwashing liquid soap and disinfectant spray stored in the resident's room on a shelf above the handwashing sink. There were 88 residents residing I the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one (Resident #1) out of three residents sampled for elopement. to ensure Resident #1's safety as evidenced by On 03/03/2025 Resident #1 a vulnerable resident left the facility undetected through the first floor's exit door and walked seven to eight blocks to his home. There were 93 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to implement infection control protocols for the disinfectant wipes on two out of three floors in the facility, as evidenced by one container of expired disinfectant wipes observed on the second floor and two containers of expired disinfectant wipes on the third floor, and two containers of disinfectant wipes with expiration dates that were illegible. There were 85 residents residing in the facility at the time of survey. On [DATE] at 9:55 AM, during a facility tour, disinfectant wipes were observed secured to the walls. Further observations revealed one container of disinfectant wipes on the second floor and two containers of disinfectant wipes on the third floor had an expiration date of [DATE] and two other disinfectant wipes containers expiration date was not legible (photographic evidence). [...]

Inspectors wroteBased on observations record reviews and interviews, the facility's failure to ensure drugs and biologicals used in the facility are stored and labeled properly, failed to ensure expired medical supplies are discarded and failed to ensure controlled medication are reconciled in accordance with professional standards; as evidence by an antibiotic eye ointment observed with no open and or expiration date for Resident #75, two normal saline bottles on Resident# 54's night stand and an unreconciled controlled substance for Resident #76.

Inspectors wroteBased on interviews and record reviews the facility failed to notify the hospice provider of a significant change in condition for one resident (Resident #239) out of two sampled hospice residents as evidenced by no documentation indicating the hospice provider was notified of Resident #239's transfer to the hospital via emergency services.

Inspectors wroteBased on record reviews and interview, the facility failed to demonstrate effective plan of actions to correct identified quality deficiency in the problem area related to repeated deficient practice for F761-Label/Store Drugs and Biologicals. As evidenced by nurse not signing narcotic log at time of medication administration and not labeling antibiotic eye ointment with expiration and opened date. Review of the facility's survey history revealed; during the recertification survey with an exit dated 08/24/2023 the facility was cited F761 for failure to secure a controlled medication. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan revision dated 09/2024 states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment as evidenced by not providing housekeeping and maintenance services necessary to maintain an orderly, and comfortable interior for resident rooms #203, #207A, #210, #213, #215A, #217, #219, #225B, #229, #235, #236A.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for two residents (Resident # 67, and Resident # 81) out of two residents MDS reviewed for accuracy. Resident # 67 was not coded for hospice care, and Resident # 81 was inaccurately coded for discharge to the hospital and the resident was discharged home.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the physician's orders and policy for a midline intravenous (IV) dressing change for one (Resident #25) out of five residents who were receiving intravenous therapy at the facility. As evidenced by the midline dressing being dated as changed on 7/20/2023. The midline dressing was not changed for one month.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for oxygen administration for one out of four sampled residents (Resident #334).

Inspectors wroteBased on record review, observation, and interviews, the facility failed to properly secure a controlled medication for one out of three medication carts observed.