WEST COLUMBIA, SC - Federal inspectors cited NHC Healthcare - Lexington with immediate jeopardy violations in March 2025 after discovering critical failures in resident supervision and respiratory care protocols.
Immediate Jeopardy: Supervision Breakdown
The most severe violation occurred when facility staff documented a resident's return from a medical appointment that never took place. According to the inspection report, staff signed documentation indicating Resident 130 had departed for and returned from an appointment, when in reality the resident remained in the facility the entire time.
This documentation failure revealed a systemic breakdown in the facility's ability to track resident whereabouts. The violation reached the level of immediate jeopardy, the most serious citation category in nursing home regulations, indicating the practice posed an immediate threat to resident health and safety.
The facility's tracking system failed to account for basic accountability measures. Staff members signed forms confirming they witnessed a resident leaving and returning, yet the resident never left the building. This raised concerns about whether staff could accurately account for all residents at any given time.
Medical Equipment Failures Put Residents at Risk
Inspectors documented widespread failures in maintaining and monitoring essential respiratory equipment for residents with chronic obstructive pulmonary disease, sleep apnea, and asthma. Four residents experienced problems with nebulizers, CPAP machines, and BiPAP equipment that went unresolved for extended periods.
Resident 59, who required a CPAP machine for obstructive sleep apnea, reported the device had been malfunctioning for approximately two weeks. The resident stated, "Something is wrong with it for about 2 weeks. They turned it on last night, it worked for a while then it just cut off. I've been asking about getting it fixed, I need it."
When nurses tested the machine during the inspection, they confirmed it stopped functioning at pressure level 4, well below the prescribed pressure of 13. The medication administration record showed nurses had been signing off nightly that the resident used the CPAP, despite the equipment not working properly.
Sleep apnea causes repeated breathing interruptions during sleep, with oxygen saturation levels dropping dangerously low. The facility's nurse practitioner confirmed Resident 59's oxygen levels had dropped into the 80s during previous sleep studies. Normal oxygen saturation ranges from 95-100 percent, and levels in the 80s indicate significant oxygen deprivation that can damage organs and increase risk of heart attack and stroke.
The facility waited until January to contact the resident's family about needed repairs, yet the equipment remained broken through March. Staff told inspectors they had asked the family to pick up the machine for servicing, but the family member stated she had no recollection of being informed about the malfunction.
Infection Control Violations During COVID Outbreak
Inspectors found multiple infection control violations while the facility managed a COVID-19 outbreak affecting nine residents. Staff left used personal protective equipment hanging outside isolation rooms where it could contaminate clean supplies and spread infection.
On March 9, 2025, surveyors observed used face masks hanging on doors of droplet precaution rooms in six separate instances. In one case, used gloves were found balled up on a handrail outside an isolation room. Staff also left used face shields hanging near clean PPE supplies.
These practices violated both facility policy and Centers for Disease Control recommendations, which explicitly state PPE must be removed at the point of exit and should not be reused. When contaminated masks and shields hang near clean supplies, they create opportunities for cross-contamination.
The facility's Director of Nursing acknowledged she served as the infection control nurse and confirmed the facility had experienced a COVID outbreak starting February 17, 2025, which initially affected 22 residents. Despite implementing measures to contain the outbreak by maintaining consistent staffing and reducing community activities, basic infection control protocols were not being followed.
Respiratory Equipment Storage Violations
Beyond the malfunctioning CPAP machine, inspectors found systematic failures in how staff stored and maintained respiratory equipment. Facility policy required nebulizer masks and tubing to be covered when not in use and changed every three days to prevent bacterial growth and contamination.
Resident 19, who used a nebulizer for asthma and chronic sinusitis, had equipment that sat uncovered beside an artificial plant covered in dust particles. Inspectors observed the same uncovered mask over multiple days. The resident could not recall when staff had last cleaned the machine or replaced the mask.
Nebulizer equipment that sits uncovered accumulates dust, bacteria, and other contaminants. When residents inhale medication through contaminated equipment, they can develop respiratory infections or experience worsening of existing lung conditions. This risk increases significantly for residents with compromised immune systems or chronic respiratory diseases.
The care plan for Resident 19 specifically instructed staff to rinse the mask and chamber with tap water after each treatment and let it dry on a paper towel. The plan also directed staff to change nebulizer tubing and mask every three days. When nurses were interviewed, they acknowledged the tubing change date had passed and confirmed their responsibility to ensure equipment remained covered when not in use.
Similar violations occurred with Residents 14 and 46, whose CPAP masks and nebulizer equipment were repeatedly observed uncovered at bedside. When questioned, staff confirmed they understood the protocols but had not been following them consistently.
Why Proper Equipment Maintenance Matters
Respiratory equipment requires strict maintenance protocols because it interfaces directly with vulnerable lung tissue. CPAP and BiPAP machines deliver pressurized air to keep airways open during sleep. When these devices malfunction, residents experience repeated breathing interruptions that deprive the brain and organs of oxygen.
Chronic oxygen deprivation contributes to hypertension, heart disease, stroke, and cognitive decline. For residents already managing multiple chronic conditions, inadequate respiratory support accelerates health deterioration.
Nebulizers convert liquid medication into fine mist that residents inhale directly into their lungs. Contaminated nebulizer equipment can introduce bacteria, mold, or other pathogens directly into the respiratory system. This poses particular danger for residents with chronic obstructive pulmonary disease or asthma, whose compromised airways are already vulnerable to infection.
Standard medical protocols require nebulizer masks to be rinsed after each use, allowed to air dry completely, and stored in clean plastic bags between treatments. Tubing and masks must be replaced on regular schedules to prevent biofilm buildup that harbors bacteria. These protocols exist because respiratory infections in nursing home residents frequently lead to hospitalization and can be life-threatening.
Facility Response and Corrective Measures
Following the immediate jeopardy finding for the supervision violation, facility administrators implemented a sign-in and sign-out log system on March 12, 2025. The new form requires multiple signatures documenting the date and time of departure, the responsible person accompanying the resident, a witness to the departure, and corresponding information upon return.
Staff present in the facility received training on March 12, with education continuing through March 26. The Director of Nursing or designee planned to review compliance daily for 30 days, then twice weekly for 14 days, then weekly for 14 days, with ongoing monitoring through monthly quality assurance meetings.
For the respiratory equipment violations, the facility had not provided detailed corrective action plans in the available inspection documentation. The Director of Nursing stated expectations that respiratory care should follow physician orders and that masks should be stored in designated bags when not in use.
The inspection report documented violations across multiple F-tags, including F689 for the supervision failure (cited at immediate jeopardy level affecting few residents), F695 for respiratory care failures (cited at minimal harm level affecting some residents), and F880 for infection prevention and control violations (cited at minimal harm level affecting some residents).
Readers can access the complete inspection report and facility response through the Centers for Medicare & Medicaid Services Nursing Home Compare website for detailed information about all citations and corrective actions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nhc Healthcare - Lexington from 2025-03-12 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.