Palmetto Subacute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include. Observation on 02/02/2026 at 7:38 AM revealed Resident #104 in bed with eyes closed and nasal canula in place with oxygen being administered at a flow rate of 3.5 Liters Per Minute (LPM). Observations of Resident #104 on 02/03/2026 at 11:13 AM and 02/04/2026 at 10:13 AM revealed the resident was seated in a wheelchair with no oxygen in use. Review of Resident #104's clinical record revealed the resident was admitted on [DATE]. Clinical diagnoses included Pneumonitis due to inhalation of food and vomit, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include. During the initial resident and room screenings and subsequent screenings on the 2nd floor North/South Unit of the facility, the following were observed: Resident #6Observation n 02/02/2026 at 7:56 AM revealed Resident #6 in bed awake, a tube of ointment was noted on the overbed table.Observation on 02/02/2026 at 10:36 AM revealed Resident #6 was out of the facility on an appointment and ointment was noted on the overbed table in the resident's room. Review of the medical records revealed Resident #6 was admitted on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to embolism of left middle cerebral artery. The admission Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include.Record review of the facility's survey history revealed, during the Recertification Survey conducted on December 16, 2024, through December 19, 2024, F761 was cited as the facility failed to ensure drugs and biologicals used in the facility were stored and labeled properly. Review of the facility policy and procedure titled Quality Assurance and Performance Improvement Plan revision date 09/2025 states: Purpose: Quality is defined as meeting or exceeding the needs, expectations, and requirements of the patients cost-effectively while maintaining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include. On 02/02/2026 starting at 06:30 AM, during the initial resident and room screenings on the 2nd floor North/South Unit of the facility, the following were observed: On 02/22/2026 at 6:38 AM revealed Resident #101 in bed with eyes closed. Cleaning supplies (dishwashing liquid soap, disinfectant spray) were stored in the resident's room on a shelf above the handwashing sink. On 02/03/2026 at 9:20 AM Resident #101 was out of facility on an appointment, the cleaning supplies- (dishwashing liquid soap, disinfectant spray), remained stored in the resident's room on a shelf above the handwashing sink. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Review of the facility policy titled wandering Elopements dated 01/28/25 indicate: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the facility policy and procedure titled accidents and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). On [DATE] at 10:03 AM, a visual tour to look at the disinfectant wipes was conducted with the Minimum Data Set (MDS) Coordinator on the second and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1) On [DATE] at 9:07 AM, review of the second floor North Medication Cart#2 with Staff B, Registered Nurse (RN). revealed one antibiotic eye ointment for Resident#75. without an open date or expiration date prescribed for Resident# 75, the label read dispense date [DATE] (photo). The Medication Administration Record revealed it was last administered on [DATE] at 1:00 PM to Resident#75. When asked what was the open or expiration date Staff B, RN reported it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: Record review of Resident #239's demographic face sheet revealed an initial admission dated 8/23/21 a readmission date of 7/29/22 and a discharged date of 7/4/24 with diagnosis that include Alzheimer's disease with late onset. Review of Resident # 239's physician's order sheet indicated an order dated 9/1/22 for: Routine Hospice Care for diagnosis of End stage Alzheimer's. Record review of Care plan initiated on 9/2/22 and revised on 8/15/24 revealed Resident #239 was at end of life with a of terminal illness and has chosen a palliative approach to care, comfort Care and is under hospice services with a goal that Resident #239 will receive comfort/palliative care according to individual wishes and facility policy through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: Our QAPI plan includes the policies and procedures used to identify and use data to monitor our performance and establish goals, thresholds for improvement measures, and data at the facility, state, and national levels. Such data and performance measures will be used to: i. Identify and monitor our performance ii. Establish goals and thresholds for our…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: Review of the facility's policy and procedure noted the following: Homelike Environment dated 03/08/2023. Policy Statement: Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to extent possible. Policy Interpretation and implementation: 1. Staff provides person-centered care that emphasizes the resident's comfort, independence and personal need and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a) Clean, sanitary and orderly environment. b) Personalized furniture and room arrangements. c) Clean bed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1. Record review of the clinical records for Resident # 67 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Other Specified Degenerative Diseases of Nervous System; Dysphagia Following Other Cerebrovascular Disease; Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety; Unspecified Psychosis Not Due to a Substance or Known Physiological condition; Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, Unspecified. Record review of the Physician Orders dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: In an observation on 08/21/23 at 02:45 PM, Resident #25 was awake and sitting in a wheelchair. A midline intravenous catheter to the right arm was observed. The midline dressing was dated 7/20/23. (See photo evidence) In an observation on 08/22/23 at 11:07 AM, Resident #25 was awake in bed, and it was observed that the dressing to the midline was changed and dated 8/21/23. (See photo evidence) In an interview on 08/23/23 at 02:46 PM with the Director of Nursing (DON). When asked, What is your facility's policy for midline dressings changes for residents? The DON stated It is the night shift nurse's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). The findings included: Observation on 08/21/23 at 10:32 AM revealed, Resident #334 was lying in bed sleeping. Further observation showed the resident was receiving oxygen therapy; the oxygen concentration level was at 3.5 LPM (liters per minute). (photo evidence obtained) Review of the physicians order dated 08/18/2023 revealed, an order for Oxygen (O2) via nasal cannula at 2L/min as needed for O2 sat <92% as needed for SOB (shortness of breath). Review of Resident #334's medical diagnoses dated 08/17/2023 revealed, Gout unspecified (primary), essential (primary) hypertension, myocardial infarction, chronic kidney disease, and polyneuropathies. Review of Resident #334's progress notes dated 08/21/2023 (e-medication administration notes) revealed, an Oxygen via nasal cannula at 2L/min as needed for O2 sat <92% as needed for SOB was administered. Further review revealed, on 08/22/2023 an Oxygen via nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interviews, the facility failed to properly secure a controlled medication for one out of three medication carts observed. The findings include: On 08/21/23 at 09:38 AM, during a medication cart observation with Staff A, Registered Nurse (RN) on Two - South - cart one. The Surveyor observed the narcotic count binder was placed on top of the treatment cart next to Staff A's medication cart. Staff A, RN and the Surveyor performed a narcotic count, and it was correct, but the Surveyor observed a bingo card containing one remaining Lorazepam 0.5 mg(milligram) tab at the end of the narcotic count sheets with its narcotic count record sheet. On 08/21/23 at 09:45 AM, in an interview with Staff A, RN, when asked, How are controlled substances to be stored and reason the Ativan was placed in the back of the binder? Staff A, RN stated, these medications are always to be stored in a locked box. The nurse from the previous shift did this. Review of the narcotic count sheet revealed, Lorazepam 0.5 mg tab was signed out on 8/21/23 a 4:45 PM with one tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.