Quality Life Services - Chicora

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9). Findings Include: Interview on 6/26/26, at approximately 12:00 p.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. During an observation on 6/26/26, at 10:45 a.m. Resident R1's former room had large patches of paint missing with exposed drywall. The floor around the commode in the in-room restroom was damaged with the subfloor visible in spots, potentially causing a fall risk and infection control risk. During an observation on 6/26/26, at 10:49 a.m., the room assigned to Resident R2, R3, R4, and R5 revealed numerous gouges in the floor. [...]

Inspectors wroteBased on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of ten residents identified to be elopement risks not who did not reside on a secured unit (Resident R10). This was identified as past non-compliance.

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not securing maintenance equipment behind a secured door as required (Dining room outside of the kitchen). Findings Include: Interview on 3/9/26, at 2:00 p.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. During a facility tour on 3/9/26, at 11:00 a.m. the Resident Dining Room directly outside of the facility kitchen, revealed the following equipment being stored: maintenance equipment and carts, resident hand railings (not attached to the wall), a nail gun, a drill with bits, a case of metal ratchets and pieces, scraping tools, shop vacuum, fans amongst other repair tools. [...]

Inspectors wroteBased on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three residents (Resident R1).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow droplet precautions for one of four residents in isolation precautions (Resident R2).

Inspectors wroteBased on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for one of 34 resident rooms (room [ROOM NUMBER]) and two of three resident areas (Millers Common Room and Dining Room). Findings Include:Review of the facility policy Extreme Weather dated 12/1/25, indicated excessive cold for lengthy periods of time can negatively impact center operations. Excessive cold poses a severe potential harm to confused exit-seeking residents. Geriatric residents have a greater risk of suffering hypothermia because their bodies do no effectively regulate internal temperatures. During an interview on 1/28/26, at 9:30 a.m. the Nursing Home Administrator (NHA) revealed that on 1/25/26, the boiler (form of heat source) needed reset. Observations conducted on 1/28/26, from 12:15 p.m. to 12:45 p.m. [...]

Inspectors wroteBased on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of 17 residents (Resident R1).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the walk-in cooler which created the potential for cross contamination in the designated main kitchen.

Inspectors wroteBased on review of facility policy, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one of three residents (Resident R94) and failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three resident's (Resident R35). Review of the facility policy Accidents and Incidents dated 10/13/25, indicated a safe environment will be promoted for all residents. Review of Resident R35's admission record indicated she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Residents R24, R41, and R81).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of three residents (Residents R1, R63, and R92).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for four of four nurse aide (NA) personnel records (NA Employees E12, E13, E14, and E15).

Inspectors wroteBased on review of the Quality Assurance attendance records and staff interview it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for three of three quarters (Quarter one, two, three of 2025).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R5), failed to ensure that contact precautions were ordered for two of five residents (Residents R36 and R82) and failed to ensure that contact precautions were care planned for one of five residents (Resident R82)

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R25).

Inspectors wroteBased on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a scoop mattress (a specialty medical mattress with soft raised foam edges) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of three residents (Resident R63).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R92).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of two residents (Residents R13 and R92).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medication rooms (Memory Lane Medication Room).

Inspectors wroteBased on a review of facility provided documents and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to follow resident consent for pneumococcal vaccination and failed to administer the vaccination in a timely manner for one of five residents (Resident R65).

Inspectors wroteBased on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E15).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post complete contact information for State Long-Term Care Ombudsman program and complete contact information for State Survey Agency at the facility as required.

Inspectors wroteBased on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility for one of five staff members (LPN, Employee E1) and two of five staff members (LPN, Employee E2 and Registered Nurse, Employee E3) annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after abuse/neglect allegations were made. This failure created an immediate jeopardy situation.

Inspectors wroteBased on review of state laws, facility policy and facility documents, and staff interviews, it was determined the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies to protect residents for one of five staff members Licensed Practical Nurse (LPN, Employee E1). This failure created an immediate jeopardy situation.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage and implement the facilities abuse and neglect policy, and failed to report alleged criminal activity of a Licensed Practical Nurse (LPN) Employee E1 to the proper authorities, which created an immediate jeopardy situation for all 95 of 95 residents.

Inspectors wroteBased on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10).

Inspectors wroteBased on review of clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents reviewed (Resident R4).

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for one of three residents (Resident R8).

Inspectors wroteBased on review of facility policies, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident R4).

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to ensure a resident is provided non-pharmacological interventions and an assessment prior to administering as needed pain medications for one of seven residents (Resident R1).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to implement fall prevention interventions and conduct post fall monitoring for one of four residents (Resident R4).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R6).

Inspectors wroteBased on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to one of five direct care facility staff reviewed (Employee E5).

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse was completed for one of four residents (Resident R1). Review of the facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation last reviewed 11/8/24, indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type with a resident and includes sexual harassment, sexual coercion or sexual assault. Reporting/Response includes but not inclusive to: [...]

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined the facility failed to properly date and store food products, and failed to maintain clean equipment in a manner to prevent foodborne illness in the Main Kitchen.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of six residents sampled with facility-initiated transfers (Residents R2, R13, R82, R83, and R88).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of six resident hospital transfers or therapeutic leave of absence (Resident R2, R69, R82, and R83). Findings Include: Review of the facility policy Notice of Bed Hold Policy at Time of Transfer Due to Hospitalization or Therapeutic Leave indicated that the bed hold policy will be provided to residents at the time of transfer of a resident for hospitalization or therapeutic leave. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess a resident for safe smoking for one of two residents (Resident R42), and failed to make certain each resident received adequate monitoring of elopement (leaving an area without permission) prevention devices for three out of three residents (Residents R67, R69, and R72)

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain a medication room refrigerator containing narcotics was properly locked and that open medications stored in the medication room refrigerator were labeled with a dated upon opening for one of two medication rooms ([NAME] Crossings Medication Room), failed to store medications and treatments for residents properly to prevent cross contamination for two of four medication carts ([NAME] Crossing Medication Cart and Settlers Cart 6), and failed to label medications upon opening and ensure medication was in pharmacy labeled medication bag for two of four medication carts ([NAME] Crossing Medication Cart and Settlers Cart 6). [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of four residents (Residents R16 and R68), failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46), failed to review annual infection control policies for ten out of ten years (2014 through 2024), and failed to notify residents or resident representatives of two out of two outbreaks ( COVID and Norovirus (a virus causing nausea, vomiting, and diarrhea)). [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for two of six residents (Resident R35 and R55).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to notify the physician of a change in condition for one of seven residents (Resident R1).

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R84).

Inspectors wroteBased on review of facility policy, observation clinical record review and staff interview it was determined that the facility failed to obtain a physician order and develop a resident centered care plan for the placement of a bed against the wall for one of two residents (Resident R42). Review of the facility policy Physical Restraint dated 7/22/24, last reviewed 11/8/24, indicated each resident is to attain and maintain his/her highest practical well-being in an environment that prohibits the use of restraints for discipline or convenience and limits use of restraints use to circumstances in which the resident has medical symptoms that warrant the use of restraint, the use of restraint will be a last resort alternative intervention. Review of the facility Resident Rights dated 7/22/24, last reviewed 11/8/24, indicated a resident shall be free of restraints. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for residents with an indwelling urinary catheter (a tube inserted in the bladder to drain urine) for one of four residents reviewed (Residents R88).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents reviewed (Resident R57, and R59).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of three quarters (January 2024 through March 2024).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E9).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not using the safest transfer status for one of two residents (Resident R2).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of 15 residents (Resident R1), failed to accurately complete assessments and monitor safety device for 15 out of 15 residents, and failed to ensure that residents were transfered safely using the safest transfer status for one of two residents (Resident R2)

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a clean safe homelike environment in one of five shower rooms (Miller's Crossing Nursing Unit Shower room).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents (Resident R1) resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of three residents (Resident R1) resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) to rule out neglect for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after a resident eloped (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R1).

Inspectors wroteBased on observations, facility policy and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen and one out of four unit refrigerators (Memory Lane) which created the potential for cross contamination and food-bourne illness.

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one out of four nursing units (Miller's Crossing).

Inspectors wroteBased on facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to implement, review, and revise a care plan after a fall for one of six residents (Resident R95).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for two of two residents (Resident R68 and R71) and failed to complete a Registered Nurse assessment on one of five residents following an injury (Resident R95).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the removal of a urinary catheter as required for one of five residents (Resident R51).

Inspectors wroteBased on facility policy, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R17).

Inspectors wroteBased on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R58).

Inspectors wroteBased on review of policies, information provided by the facility, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that staff report an allegation of abuse per the facility's policy for one of 30 residents reviewed (Resident 28). This deficiency was cited as past non-compliance.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident ' s care plan was updated and revised to reflect the resident ' s specific care needs after a resident refused elopement interventions, for one of two residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of two residents (Resident R1).