NHC Healthcare - Bluffton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)6 received necessary behavioral health services in a timely manner. R6 consented to behavioral health services on 07/17/25, the facility did not acknowledge the consent/referral until 11/20/25. During this lapse of behavioral health services, R6 had several depressive and anxiety related symptoms, this non-compliance had the potential to place the resident at risk for further emotional distress, for 1 of 4 residents reviewed for mood/behaviors. Findings include:Record review of facility policy titled Patient Care Policies last revised 03/25 revealed Physician or physician extender requested consultations including but not limited to, dental services, podiatry, optometry, audiology, physiatry or mental health services will be arranged by the center with the consent of the patient or patient representative. A non-physician practitioner (NPP) may request and/or perform a consultation service within 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 review of facility policy, record review, review of a police incident report, witness statements, and interviews, the facility failed to ensure that Resident (R)1 received adequate supervision to prevent a successful elopement from the facility on 06/22/25 at approximately 3:15 PM. Specifically, R1 was found by 2 Samaritans, facility staff, and law enforcement outside of the facility. Per police incident documentation, R1 was found near a wooded swamp area near the facility's parking lot. R1 was observed covered in dirt and in need of toileting care (R1's pants was saturated with urine).On 07/18/25 at 12:57 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 07/18/25 at 12:57 PM, the Administrator was notified that the failure to provide appropriate supervision for a resident, which resulted in the resident successfully…

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, observations, and interviews, the facility failed to ensure foods that are stored in the refrigerator, freezer, and dry storage areas were labeled, appropriately stored and sealed, and discarded after the manufacturer's expiration date. This deficient practice has the potential to increase foodborne illnesses. Findings Include: Review of the facility's policy titled, Refrigerator and Freezer Storage, dated 11/2017 states Refrigerated and frozen foods will be stored properly for optimal product safety. 9. A) Foods will be stored in their original container or a NSF approved container or wrapped tightly in moisture proof film, foil, etc. Clearly labeled with the contents and the use by date. (Food Code 3-501.17). 10. Leftovers will be placed in NSF approved containers, covered, labeled, dated, and stored in refrigerator or freezer at correct temperature. During an initial tour on 11/12/24 at 10:17 AM, in the walk-in refrigerator, accompanied by the Kitchen Manager (KM),…

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, observations, and interviews, the facility failed to ensure expired medication was removed from medication and treatment carts and properly label a medication bottle for 2 of 3 units reviewed for medication storage. Additionally, the facility failed to secure a medication cart for 1 of 3 units reviewed for medication storage. Findings include: Review of the facility policy dated 01/01/2019, titled, Disposal of Medications and Medication Related Supplies, revealed, Unused, unwanted, discontinued, expired and non returnable medications should be removed from their storage area and secured until destroyed. Review of the facility policy dated 01/01/2029, titled, Storage of Medications revealed, All medications dispensed from the pharmacy are stored in the container with the pharmacy label. An observation of the 100 Hall Medication Room on 11/13/24 at 9:45 AM with Licensed Practical Nurse (LPN) Unit Manager (UM)5 revealed, an ice cream bar inside of the medication room freezer. LPNUM5 stated This was not in the freezer when I checked it earlier.…

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, interviews, record review, and facility policy review, the facility failed to properly store and label an nasal respiratory inhaler for 1(Resident (R)44) of 1 resident reviewed for respiratory care and services. Findings include: Review of a facility policy titled, Oxygen Administration & Nursing Services, revised date of 03/2024, revealed Oxygen Administration: 1. Verify that there is a physician's order for this procedure. Review the physician's/provider's orders for oxygen administration. Nursing Services: D. Medications, treatment and diets are given as ordered and are documented in the electronic health record. (Only licensed nurses administer medications, except in states where certified medication technicians are allowed.) A review of the R44's electronic medical record revealed the facility admitted R44 on 10/04/24, with diagnoses that included not limited to periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of R44's Medication…

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 administer medications to Resident (R)1 in a clinically appropriate manner for 1 of 2 residents reviewed for self-administration of medications. Findings include: Review of the facility policy titled Medication Administration last revised 01/01/19 revealed Medications are administered in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility staff and a medication distribution system ensure the safe administration of medications without unnecessary interruptions. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. The 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.

Based on interviews, record review and document reviews, the facility failed to timely complete the quarterly Minimum Data Set (MDS) assessments for Resident #1, Resident #4, and Resident #15; 3 of 5 residents reviewed for resident assessment. Findings include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2019, revealed, 5.2 Timeliness Criteria In accordance with the requirements at 42 CFR (code of federal regulations) §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: -For all non-admission OBRA and PPS assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD). 1. A review of Resident #1's quarterly MDS with an assessment reference date of 09/08/2022, revealed the assessment was signed as being completed on 10/21/2022 by MDS Coordinator #2. A review of the CMS Submission Report for the facility with a submission date of…

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, record review, and facility policy review, the facility failed to assess for safe self-administration of medications for 2 (Residents #10 and #55) of 8 residents reviewed for self-administration of medications. Findings included: A review of the Self-Administration of Medications, dated 01/01/2019, revealed, In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. C. The results of the interdisciplinary team member's assessment of resident skills and of the determination regarding bedside…

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 interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was free from resident-to-resident physical abuse for 1 (Resident #23) of 7 sampled residents reviewed for abuse and/or neglect. Specifically, Resident #23 was slapped in the face by Resident #24, who had a history of combative and physically aggressive behaviors with staff. Findings included: Review of a facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, revealed, Definitions Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also indicated, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, the policy indicated, Physical Abuse:…

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, record review and document reviews, the facility failed to timely complete the admission and annual Minimum Data Set (MDS) assessments for Resident #3 and Resident #212; 2 of 5 residents reviewed for resident assessment. Findings include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2019, revealed, 5.2 Timeliness Criteria In accordance with the requirements at 42 CFR (code of federal regulations) §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: For all non-admission OBRA and PPS assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD). For the admission assessment, the MDS Completion Date must be no later than 13 days after the Entry Date. A review of the CMS Submission Report for the facility with a submission date of 10/26/2022, revealed Resident #3's assessment with a target date (assessment reference…

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.