Life Care Center of Hilton Head

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and manufacturer labelling, the facility failed to ensure that medications were securely stored on 1 of 4 medication carts observed during medication pass and further failed to ensure that expired and outdated medications were removed from 4 of 4 medications carts and 2 of 2 treatments carts.Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised on 08/01/24 states, Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated 12/01/2007 and the latest revision date of 08/01/2024, states as the procedure under, General . 10. Facility should ensure medications and biological's that: 1) Have an expired date on the label; 2) Have been retained longer than…

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 review of facility policy, observation, interview, and record review, the facility failed to ensure residents were provided showers or baths for 5 out of 5 residents and nail care for 1 of 5 residents reviewed for activities of daily living. Findings include:Review of the facility policy titled, Activities of Daily Living (ADL) with a reviewed date of 09/10/24, revealed, Residents will receive assistance as needed for completing ADLs. Additionally, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility policy titled, Refusal of Care or Treatment with a reviewed date of 09/05/24, revealed, If the resident refuses other care activities such as bathing, the facility should speak with the resident and/or resident representative to determine if the preference or tolerance for this activity has changed. The interdisciplinary team should work with the resident and/or resident…

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 review of facility policy, record review, and interviews, the facility failed to ensure an allegation of abuse was reported in a timely manner. Specifically, the facility was notified of an allegation of sexual abuse on 07/09/25 and did not report the allegation of abuse to the State Agency until 07/16/25.Findings include:Review of the facility's policy, with a reviewed date of 09/05/24, titled, Incident and Reportable Event Management, states, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey…

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 review of facility policy, observation, record review, and interview, the facility failed to ensure that a nutritional supplement was accurately measured as to volume as specified in physician orders for 1 of 5 residents observed during medication pass administration.Findings include:Review of the facility policy titled Administration of Medications reviewed on 09/16/24 states, Right Dose. Check the MAR (Medication Administration Record) and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers.Review of Resident (R)6's Face Sheet revealed R6 was admitted to the facility on [DATE], with diagnoses including but not limited to, protein-calorie malnutrition.On 07/17/25 at approximately 8:18 AM, during medication pass observations for R6 revealed Registered Nurse (RN)2 poured Med Pass 2.0 Vanilla into a plastic cup without measuring the amount. When asked how much she had poured into the plastic cup, RN2 stated she had no way of measuring…

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 review of facility policy, record review, and interview, the facility failed to accurately document Resident (R)510's advance directives, for 1 of 2 residents. Specifically, R510 had orders and signed documentation requesting Do Not Resuscitate (DNR), however R510's Care Plan documented Full Code. Findings include: Review of the facility policy titled, Advance Directives and Advance Care Planning with a reviewed date of [DATE], documented, Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive . Procedure 15. Documentation in the Minimum Data Set (MDS) should reflect the appropriate advance directives . 16. Do Not Resuscitate (DNR) - . all Life Care Centers of America's residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's advance directive .…

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, record review, and review of facility policy, the facility failed to revise Resident (R)4's Care Plan to reflect refusal of Activities of Daily Living (ADL) care in a timely manner, for 1 of 3 residents reviewed for Care Plans related to ADL Care. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions last revised on 08/22/23 revealed, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Procedure includes: the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When…

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, interview, record review, and review of facility policy, the facility failed to offer/provide Resident (R)4, a dependent resident, with Activities of Daily Living (ADL) care related to facial hair, for 1 of 3 residents reviewed for ADL care. Findings include: Review of facility policy titled Activities of Daily Living: last revised 02/12/24 revealed The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services that ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming,…

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, record review, and review of facility policy, the facility failed to ensure that medications were properly stored and secured for Resident (R)15, for 1 of 1 residents reviewed. Findings include: Review of facility policy titled, , Storage and Expiration Dating of Medication, Biologicals with an effective date of 12/01/07, revealed, Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Facility should ensure that only Facility representatives and the appropriate resident maintains the keys, access cards, electronic codes, or combinations which…

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 National Pressure Injury Advisory Panel, record review, interview, and observation, the facility failed to failed to provide physician supervision of a pressure ulcer for Resident (R)49's right foot, for 1 of 4 residents reviewed for pressure ulcers. Findings include: Review of the National Pressure Injury Advisory Panel, titled, Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide, dated 2019 revealed under recommendation, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location;…

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 review of the facility policy, observation, and interview, the facility failed to follow infection control standards during wound care of Resident (R)49, for 1 of 4 residents reviewed for pressure ulcers. Findings include: Review of the undated facility policy titled, Wound Care Treatment Clean Dressing Change Skills Evaluation revealed under policy, Wound Care; gently remove the old dressing and place in the trash, discard soiled gloves, clean hands. Hand hygiene; hand washing or hand sanitizer per policy. Review of R49's Face Sheet revealed the facility admitted R49 on 02/07/24, with diagnoses including but not limited to: hip fracture, pressure ulcer of right heel unstageable, weakness and orthostatic hypotension. During an observation of a dressing change for R49 on 06/05/24 at 11:41 AM, Licensed Practical Nurse (LPN)2 gathered all the supplies needed for the dressing change and placed them on a clean tray, lined with a barrier. LPN2 knocked on the door and entered the room and closed the door. R49 gave consent for an observation of the dressing change. R49 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure accurate resuscitation code status documentation was maintained in both the electronic medical record (EMR) and paper medical record for one resident (Resident (R) 98) of 24 sampled residents. Findings include: Review of a policy provided by the facility titled Advance Directives and Advance Care Planning, dated 10/20/21, indicated . The ability of a person to control decisions about medical care and daily routines has been identified as one of the key elements of quality of care at the end of life. The process of advance care planning is ongoing and affords the resident, family, and others on the resident's interdisciplinary health care team as opportunity to reassess the resident's goals and wishes as the resident's medical condition changes . Review of a document provided by the facility titled Emergency Medical Services Do Not Resuscitate (a directive not to perform cardiopulmonary resuscitation and to allow natural death)…

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 policy review, the facility failed to ensure one Certified Nursing Assistant (CNA)9 was provided needed competency training for oxygen administration and maintenance. As a result, CNA9 failed to recognize that an oxygen canister required for care of a resident (Resident (R)9) was empty and needed to be replaced. This failure had the potential to cause physical and/or psychosocial harm to residents requiring oxygen therapy administration. Findings include: Review of a document provided by the facility titled Oxygen Administration/ Safety/ Storage/ Maintenance, reviewed on 08/02/21, reflected under Training Requirements: All facility staff will be educated on Oxygen Administration, Safety and Storage upon hire, annually, and as indicated thereafter. The same policy noted Procedure: This facility will utilize the following Lippincott procedures: Oxygen Administration Procedure: Oxygen Administration Competency Skills Checklist: with embedded links to the Lippincott Manual (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 interview, record review, and policy review, the facility failed to ensure one of five residents (Resident (R) 30) reviewed for unnecessary medications had a documented rationale for declining pharmacy recommendations. Findings include: Review of the facility policy Pharmacy Services and Medication Regimen Review, dated 11/18/21, revealed, Procedure: Unless otherwise required, the facility will utilize the Omnicare 09.01 Medication Regimen Review procedures for handling Drug Regimen Reviews. Review of Omnicare 9.1 Medication Regimen Review, dated 11/28/16, revealed Applicability: This Policy 9.1 sets forth procedures relating to the medication regimen review (MRR). Procedure: 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendation contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon 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, policy review, and review of Center for Disease Control and Prevention (CDC) guidance, the facility failed to ensure: 1. one of one resident (Resident) R99 reviewed for new admissions was placed under quarantine. R99 was unvaccinated for COVID-19. and 2. a catheter bag was kept off the floor for one of one resident (Resident (R) 19) in a total sample of 24 residents. The failure to quarantine an unvaccinated new admission increased the risk of transmission of COVID-19 to other residents. The failure to keep a catheter bag off the floor increased the risk for R19 developing a urinary tract infection. Findings include: 1. Per CDC website titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, revealed Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection indicated . HCP (healthcare personnel) caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (personal…

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.