MUSC Health Mullins Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to store food in the Walk-In Coolers, Freezer, and Unit Refrigerators, in accordance with professional standards for food service safety out of 1 of 1 Kitchens observed and 2 of 3 Unit Refrigerators observed. Findings include: Review of facility policy titled Food and Supply Storage last revised on 01/25, revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of food for human consumption. Procedures include cover, label, and dated unused portions and open packages. Use the Medvantage/Fresh date labeling system or completed all sections on a [NAME] orange label. Products are good through the close of business on the date noted on the label. Review of facility policy titled Cleaning of Food and Non-food Contact Surfaces last revised on 01/25, revealed, Non-food contact surfaces of equipment such as handles on…

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 the facility policy, observation and interview, the facility failed to remove expired medications from 2 of 4 medication carts. Findings include: Review of the facility policy titled, Medication Storage with an origination date of 01/01/07, and an effective date of 06/11/24, documents, The facility shall store all drugs and biological's in a safe, secure, and orderly manner . Is to provide guidelines for the storage of medications in the Medications Rooms, the Medications/Treatment carts and in the approved stock areas . The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. Such drugs shall be returned to the dispensing pharmacy or destroyed. During an observation on 05/16/25 at 10:31 AM, of the 2 [NAME] Hall Med Cart A, revealed the medication Aspirin 325 milligrams ([NAME] Aspirin) with Lot #134414, expired on 04/2025. During an observation on 05/16/25 at 10:40 AM, of the 2 [NAME] Hall Med Cart B, revealed the medication Aspirin 81 milligrams EC with Lot…

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 facility policy, observations and interview, the facility failed to ensure proper labeling/dating and discarding of foods stored in 1 of 1 kitchen. Findings include: Review of facility policy titled Food and Supply Storage Procedures last revised 01/31/16 revealed, .all food, non-food items, and supplies used in food production shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of food for human consumption. Most products contain an expiration date, the words 'sell-by', 'best-buy', or 'use by', should precede the date. The 'sell-by', 'best-buy', or 'use-by' date is the last date that food can be consumed. Foods past the 'use-by', 'sell-by', or 'enjoy-by' date should be discarded. Cover, label, and date unused portions and open packages, use the orange label and complete all sections on the label. In frozen storage, procedures include food stored frozen should be kept no longer than three months for quality purposes; date and rotate items first in, first out, discard food past the use-by or expiration date. During…

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 facility policy, observations and interviews, the facility failed to follow a procedure during Foley catheter care to prevent and/or decrease the likelihood of infection for Resident (R)64, for 1 of 1 residents reviewed for catheter care. Findings include: Review of the undated facility policy titled, Urinary Catheter Care states, It is the policy of this nursing center to deliver appropriate catheter care in the manner to prevent urinary tract infections and to restore as much normal bladder function as possible to those residents with indwelling catheters. Procedure: Wash and dry hand thoroughly. Provide privacy. Cover the Resident with a sheet, exposing only the perineal area. Put on clean gloves. With a non dominant hand separate the labia of the female resident. Maintain the position of the hand throughout the procedure. Access the urethral meatus. FOR THE FEMALE: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward stroke. Next change the position of the washcloth and cleanse around the urethreal…

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 reviews and interviews, the facility failed to follow a procedure to ensure gastric residual did not exceed 100 milliliters for 1 of 1 residents reviewed for a peg tube with enteral feedings. Specifically, the gastric contents, when the residual was aspirated from the tubing, was 1000 milliliters (1 liter) for Resident (R)74. Findings include: Based on the undated facility policy titled Enteral Tube Medication Administration states, The facility policy assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietician, and consultant pharmacist. Review of The [NAME] & [NAME] Nursing Manual dated 2023, states, Assess residual volume every 4 to 6 hours for continuous feeding and just before each…

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 facility policy, observations and interviews, the facility failed to ensure proper hand hygiene was followed during Foley catheter care to prevent and/or decrease the likelihood of infection for Resident (R)64, for 1 of 1 residents reviewed for catheter care. Findings include: Review of the undated facility policy titled Hand Hygiene states, The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. Proper hand hygiene is expected of all employees in utilizing the most important way of helping to prevent the transmission of infection. Guidelines: I. Hand hygiene is always indicated: D. Before and after contact with any source likely to be contaminated (equipment, devices in work area or resident's room). E. After contact with body substances or contact with a piece of equipment or device contaminated with body substances. F. Between tasks on same resident. (i.e. indwelling catheter care or mouth care, etc.) II. The wearing of gloves does not replace the need for practicing proper hand hygiene. Review of R64's Face Sheet revealed…

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 ensure two out of two sampled residents (Residents (R) R16 and R66) had a Level II Pre-admission Screening and Resident Review (PASARR) evaluation completed despite being diagnosed with a serious mental disorder (MD) and/or intellectual disability (ID). Specifically, R16 had a diagnosis of bipolar disorder and R66 had a diagnosis of schizophrenia disorder. This failure placed the residents at risk for unmet care needs and for not receiving appropriate mental health support/services and treatment/s needed. This deficient practice had the potential to affect all facility residents who were given or had been diagnosed with a MD or ID diagnosis. Findings Include: 1. Review of R66's Electronic Medical Record (EMR), Face Sheet stated, R66 was admitted on [DATE] with diagnoses including, but not limited to schizophrenia, atrial fibrillation, and diabetes. Review of R66's EMR and admission Minimum Data Set (MDS) (an assessment used to determine plan of care…

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 record review, staff interview, and facility policy review, the facility failed to maintain an effective Falls Management program as evidenced by not investigating falls and/or conducting a thorough root cause analysis to identify potential environmental and safety hazards and resident-specific fall interventions to reduce and/or eliminate repeated falls for one sampled resident (Resident (R) R16), who had repeated unwitnessed falls that could have resulted in harm, injury, or death. Findings include: The facility failed to adhere to the guidelines and practices as described in the facility's Falls Management policy. The purpose of the policy was To provide guidelines for identification, investigation and documentation of resident fall and to implement intervention to promote safety. If a fall has occurred, the policy stated that a post fall evaluation would be completed to determine what may have caused the fall. Furthermore, the policy also stated that .additional interventions or revisions may be…

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, interviews, and review of the facility's policies and procedures, the facility failed to ensure Resident (R)11 was free from unnecessary psychotropic medications for 1 of 5 residents reviewed for Unnecessary Medications. The facility further failed to ensure proper medical rational, indication for use and monitoring, was documented in the medical record. Findings include: The facility admitted R11 with diagnoses including, but not limited to Dementia without behaviors, Depression, and Mood Disorders. Review on 1/13/22 at 12:49 PM of the manufacturer's guidelines for the use of the medication, Trazodone, is indicated for the treatment of major depressive disorder in adults. Trazodone is contraindicated for use in the elderly population. An initial dose of 150 mg/day in divided doses is suggested. The dosage should be initiated at a low dose and increased gradually noting the clinical response and any evidence of intolerance. R11 is receiving 100 milligrams of Trazodone 2 times daily. She is receiving Celexa for a diagnosis of Depression. Review on 1/13/22 at…

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 review of the manufacturer's recommendations for administration of an insulin kwik pen, the facility failed to ensure an insulin pen was administered correctly for Resident (R)51, during observation of administration of an insulin kwik pen during medication pass for 1 of 25 opportunities for error. Findings include: The facility admitted R51 with diagnoses including, but not limited to, Diabetes Mellitus Type II and Kidney Disease. An observation on 1/12/22 at 9:15 AM revealed Licensed Practical Nurse (LPN)1 administering 15 units of Basaglar Insulin for R51. The nurse prepped the area with an alcohol prep and then placed the needle in the subcutaneous tissue and pressed the button and as soon as the button was pressed, she removed the needle, not waiting the 5 seconds per the manufacturer's recommendations. An interview on 1/12/22 at 9:16 AM with LPN1 confirmed she did not wait the recommended 5 seconds before removing the needle, as per the manufacturer's recommendations. Review on 1/12/22 at 10:45 AM of the manufacturer's recommendations for a…

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 review of the facility policy titled, Discharge Medications: Controlled Medication Disposal, the facility failed to ensure discontinued controlled medications were removed from storage with controlled drugs for resident use in 1 of 4 medication carts reviewed. Findings include: An observation on 1/12/22 at 3:20 PM of the 200 Hall North medication cart revealed the medication Tramadol HCL 50 milligams, 6 tablets, manufacturer [NAME], with RX #4246204 discontinued and stored in the medication cart with other controlled drugs for resident use. Also observed in the 200 Hall North medication care were Oxycodone-APAP 5-325 milligrams 20 tablets manufacturer J. Seulewski, RX#2069341 discontinued on 12/21/21 and still stored in the North 200 Hall medication cart with other controlled drugs for resident use. An interview on 1/12/22 at 3:21 PM with the Director of Nursing, the nurse passing medications on the 200 Hall North medication cart, confirmed the findings and stated, It takes 2…

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.