Premier Living And Rehab Center

F-F580: Based on record review, and staff, resident, and Physician interviews, the facility failed to notify the physician that the scheduled medication gabapentin, a medication ordered for nerve pain that is not to be Level of Harm - Immediate stopped abruptly, was not administered. Resident #51 was prescribed gabapentin 800 milligrams (mg) four jeopardy to resident health or times daily for nerve pain. Resident #51 missed a total of 21 doses of the medication from 5/8/24 through safety 5/13/24 and had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms and the physician was not notified of this. Resident #46 Residents Affected - Some was prescribed gabapentin 800 mg two times daily for nerve pain. The physician was not notified that Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, the facility failed to notify the physician that 14 doses of the antibiotic Amoxicillin 875 mg was administered to Resident #39 instead of the antibiotic Augmentin (Amoxicillin-Clavulanate 875 mg-125 mg) that was ordered by the physician on discharge from the hospital. This deficient practice affected 3 of 10 residents reviewed for notification.

F-F697: Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600

F-F755: Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Physician interview, the facility failed to ensure scheduled medication was obtained and Level of Harm - Immediate available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for jeopardy to resident health or medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. safety The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale Residents Affected - Some of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication. She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600

F-F760: Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant Level of Harm - Immediate medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident jeopardy to resident health or #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was safety administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart Residents Affected - Some failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being

the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE REDACTED] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of

the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in

the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant).

An interview was conducted via phone with the Physician on 6/18/24 at 1:20 pm. The Physician indicated it was the facility's responsibility to provide the services necessary for the residents.

An interview was conducted in person with the Director of Nursing (DON) on 6/14/24 at 4:10 PM. The DON indicated that staff not providing services needed to the resident was a form of neglect. She indicated education was provided to nursing staff to educate them on providing services the residents required.

The Administrator was notified of immediate jeopardy on 6/13/24 at 5:00 PM.

The facility provided the following immediate jeopardy removal plan:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance:

The facility failed to protect Residents #46, #51, #269, and #419 from neglect as evidenced by the following deficient practices:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 580: The facility failed to notify the physician when two residents (Resident #51 and #46) were not administered their ordered gabapentin for multiple doses. Level of Harm - Immediate jeopardy to resident health or 697: The facility failed to effectively manage Resident #51's and Resident #46's pain. safety 755: The facility failed to ensure routine pain medication was obtained and available for administration for Residents Affected - Some Resident #51 and Resident #46.

760: The facility failed to prevent significant medication errors for Resident #269, Resident #419, Resident #51, and Resident #46.

The facility became aware of this neglect allegation for Resident #51 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024.

The facility became aware of this neglect allegation for Resident #46 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024.

The facility became aware of this neglect allegation for Resident #269 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024.

The facility became aware of this neglect allegation for Resident #419 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024.

The Administrator and Director of Nursing identified that all current residents have the potential to be affected by this deficient practice.

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be complete:

On 06/13/2024 the Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) began educating all staff on the facility abuse and neglect policy. This education will be on the importance of staff understanding that all residents have a right to be free of neglect and that failing to provide the necessary care and services to residents constitutes neglect. All staff will have a comprehensive understanding that the following are necessary care and services: obtaining and administering medications as ordered by provider, effectively managing pain, and notifying the physician of significant changes to include any issues with administering significant medications as ordered. The Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) will begin in person education on 06/13/2024 with all staff which will include all full-time, part-time, as needed, contract staffing departments, and agency staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 No staff member will work after 06/13/2024 until they have received the education. The Social Worker and Director of Nursing will be responsible for keeping up with staff who have and have not been educated. The Level of Harm - Immediate Social Worker, the Director of Nursing, and UMs are responsible for completing the education with all staff jeopardy to resident health or including any staff who have not been educated by 06/13/2024. The UMs were notified of their responsibility safety on 06/13/2024 by the Director of Nursing. The Social Worker and the Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to Residents Affected - Some ensure the facility implements effective systems so that residents receive the necessary care and services that are needed. The Social Worker and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator.

All newly hired staff (full-time, part-time, as needed, contract staffing departments and agency) will be educated as noted above. This will be completed by the Social Worker, Human Resources Coordinator, and/or Director of Nursing. The Social Worker, Human Resources Coordinator, and the Director of Nursing will be responsible for keeping up with new hires who have and have not been educated. The Social Worker, Human Resources Coordinator, and the Director of Nursing are responsible for completing the education with new hires. The Social Worker, Human Resources Coordinator, and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator.

Alleged date of immediate jeopardy removal: 6/16/24

The removal plan of the Immediate Jeopardy was validated on 06/19/24. A sample of staff including the Administrator, Unit Manager, nurses and medication aides were interviewed regarding in-services they received related to the deficient practice. All staff interviewed stated they had been in-serviced regarding the importance of staff understanding that all residents have a right to be free of neglect and understood that failing to provide the necessary care and services to residents constitutes neglect such as obtaining and administering medications as ordered, managing pain, and notifying the physician of significant changes.

The IJ removal date of 6/16/24 was validated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 35173

Residents Affected - Some Based on record review and staff interviews, the facility failed to submit a report of an allegation of neglect to Adult Protective Services (APS) and law enforcement within the required time frame for 4 of 4 residents (Resident #46, #51, #269 and #419) reviewed for neglect. The facility was officially notified of neglect on 06/13/24 at 2:15 PM when an immediate jeopardy template was issued. The facility did not notify APS or law enforcement within the required time frame following notification.

Findings included:

Review of the facility provided initial allegation report dated 06/14/24 regarding Residents #46, #51, #269, and #419 revealed no documentation of APS being notified and no record of law enforcement notification.

During an annual recertification survey and complaint investigation, the facility was officially notified of neglect on 06/13/24 at 2:15 PM and an immediate jeopardy template was issued to the Administrator. The immediate jeopardy template was signed by the Administrator and the Administrator was verbally informed of

the information regarding the situation involving neglect. Review of the state agency records revealed the facility submitted an initial report to the State Agency within the required time frame following the notification of neglect, however documentation supported that the facility did not notify law enforcement or APS until 06/16/24.

During a phone interview with the facility Administrator on 06/17/24 at 4:30 PM, she stated she submitted an initial allegation report to the State Agency regarding the neglect information provided on the template which

she had received on 06/13/24. She stated since the neglect was identified by the state surveying staff and

she received a template for the immediate jeopardy she was confused as to whether or not she would still have to notify APS and law enforcement. She stated it was not until she was reviewing the template and the initial allegation report on 06/16/24 when she realized she should notify law enforcement and APS and on 06/16/24 she notified both.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40044

Residents Affected - Some Based on record review, and staff interviews the facility failed to develop and implement a person-centered comprehensive care plan as indicated by the Minimum Data Set (MDS) care area assessment to include: the areas of psychosocial wellbeing, falls, nutrition, vision, communication, pressure ulcers, dental, pain, activities of daily living, and dehydration (Resident #11), at risk for nutritional status (Resident #219 and Resident #34), assistance with activities of daily living, nutrition, and urinary incontinence (Resident #52); and for not developing a comprehensive care plan for a resident receiving anticoagulant medication (blood thinner) (Resident #16). This was for 5 of 26 residents reviewed.

Finding included:

1. Resident #11 was admitted to the facility on [DATE REDACTED] with diagnoses including in part; dementia, hearing loss, and cerebral vascular accident (CVA).

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] revealed Resident #11 had moderately impaired cognition. He had moderate difficulty hearing, and difficulty communicating some words or thoughts. He had impaired vision and used corrective lenses. He had no falls and was at risk for falls. No pressure ulcers and at risk of pressure ulcers. He had broken teeth and received pain medication. He required assistance with activities of daily living. The care area assessment dated [DATE REDACTED] indicated to initiate care plans in the following areas: psychosocial wellbeing, falls, nutrition, vision, communication, pressure ulcers, dental, pain, activities of daily living, and dehydration.

Review of Resident #11's electronic medical record from admission on 08/11/23 through 06/19/24 revealed no care plan in place for Resident #11 to address psychosocial wellbeing, falls, nutrition, vision, communication, pressure ulcers, dental, pain, activities of daily living, or dehydration.

During a phone interview on 06/19/24 at 2:05 PM the MDS nurse stated she worked for an agency that was contracted with the facility and completed MDS assessments and care plans remotely. She began working for the facility on 04/30/24. She indicated although she was not the person that was responsible for creating

the initial comprehensive care plan for Resident #11, the care plans should have been completed from the care areas that triggered on the MDS admission assessment. She reviewed the MDS and care plan for Resident #11 and agreed a care plan should have been implemented in the areas of psychosocial wellbeing, falls, nutrition, vision, communication, pressure ulcers, dental, pain, activities of daily living, or dehydration.

During an interview on 06/14/24 at 4:00 PM the Director of Nursing (DON) stated she was not aware that care plans were not implemented for Resident #11. She stated there had been staff turnover with the MDS nurses. She indicated care plans should be developed and implemented according to the required CMS (Centers for Medicare & Medicaid) guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a phone interview on 06/19/24 at 4:00 PM the Administrator stated there had been staff turnover with

the MDS nurses. She reported the MDS nurse was responsible for developing care plans and care plans Level of Harm - Minimal harm or should have been initiated for Resident #11. She reported they currently utilized an agency MDS nurse who potential for actual harm worked remotely, and she planned to get an MDS nurse back in the facility as soon as possible.

Residents Affected - Some 2. Resident #219 was admitted to the facility on [DATE REDACTED] with diagnosis including cellulitis of the left lower limb and diabetes.

The MDS admission assessment dated [DATE REDACTED] revealed Resident #219 was cognitively intact. She received wound care and a therapeutic diet. The care area assessment dated [DATE REDACTED] indicated to initiate a care plan that included nutritional status.

Review of Resident #219's electronic medical record from admission on 05/22/24 through 06/19/24 revealed no care plan in place for Resident #219 to address Nutritional status with measurable goals and interventions.

During a phone interview on 06/19/24 at 2:05 PM the MDS nurse stated she was responsible for initiating the comprehensive care plan for Resident #219. She reported that she missed initiating the care plan as indicated on the MDS admission assessment in the area of nutrition. She stated it was done in error.

During an interview on 06/14/24 at 4:00 PM the Director of Nursing (DON) stated she was not aware that care plans were not implemented for Resident #219. She stated there had been staff turnover with the MDS nurses. She indicated care plans should be developed and implemented according to the required CMS (Centers for Medicare & Medicaid) guidelines.

During a phone interview on 06/19/24 at 4:00 PM the Administrator stated there had been staff turnover with

the MDS nurses. She reported the MDS nurse was responsible for developing care plans and care plans should have been initiated for Resident #219. She reported they currently utilized an agency MDS nurse who worked remotely, and she planned to get an MDS nurse back in the facility as soon as possible.

35173

3. Resident #52 was admitted to the facility on [DATE REDACTED]. Diagnoses included, in part, dementia, seizures, syncope and chronic kidney disease.

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] revealed Resident #52 was severely cognitively impaired and required assistance with activities of daily living and was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #52's weight was recorded as 193 pounds and there were no nutritional approaches indicated. The care area assessment dated [DATE REDACTED] indicated to initiate care plans in the following areas: activities of daily living, urinary incontinence, and nutritional status.

Review of Resident #52's electronic medical record from admission on 05/02/24 through 06/19/24 revealed there were no care plans in place to address nutritional status, activities of daily living, or urinary incontinence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 An interview was conducted on 06/14/24 at 4:00 PM with the Director of Nursing (DON). The DON stated

she was not aware that care plans were not implemented for Resident #52. She stated there had been staff Level of Harm - Minimal harm or turnover with the MDS nurses. She indicated care plans should be developed and implemented according to potential for actual harm the required CMS (Centers for Medicare & Medicaid) guidelines.

Residents Affected - Some A phone interview was conducted on 06/19/24 at 2:05 PM with the MDS nurse. The MDS nurse stated she worked for an agency that was contracted with the facility and completed MDS assessments and care plans remotely. She began working for the facility on 04/30/24. She indicated although she was not the person that was responsible for creating the initial comprehensive care plan for Resident #52, the care plans should have been completed from the care areas that triggered on the MDS admission assessment. She reviewed

the MDS and care plan for Resident #52 and agreed a care plan should have been implemented in the areas of nutritional status, activities of daily living and urinary incontinence.

A phone interview was conducted on 06/19/24 at 4:00 PM with the Administrator. The Administrator stated there had been staff turnover with the MDS nurses. She reported the MDS nurse was responsible for developing care plans and care plans should have been initiated for Resident #52. She reported they currently utilized an agency MDS nurse who worked remotely, and she planned to get an MDS nurse back in

the facility as soon as possible.

4. Resident #34 was admitted to the facility on [DATE REDACTED]. Diagnoses included, in part, cancer, anxiety and depression, acquired absence of kidney, and dementia.

The MDS admission assessment dated [DATE REDACTED] revealed Resident #34 was moderately cognitively impaired; weight was recorded as 155 pounds and he was on a mechanically altered diet.

The MDS quarterly assessment dated [DATE REDACTED] revealed Resident #34 was moderately cognitively impaired. Resident #34 was coded as coughing or choking during meals or when swallowing medications and weight was recorded as 139 pounds. Resident #34 had a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months and was on a mechanically altered diet.

Review of Resident #34's electronic medical record from admission on 02/01/24 through 06/19/24 revealed there was no care plan in place to address nutritional status.

An interview was conducted with the DON on 06/14/24 at 4:00 PM. The Director of Nursing (DON) stated

she was not aware that the nutritional care plan was not implemented for Resident #34. She stated there had been staff turnover with the MDS nurses. She indicated care plans should be developed and implemented according to the required CMS (Centers for Medicare & Medicaid) guidelines.

A phone interview was conducted on 06/19/24 at 2:05 PM with the MDS nurse. The MDS nurse stated she worked for an agency that was contracted with the facility and completed MDS assessments and care plans remotely. She began working for the facility on 04/30/24. She indicated although she was not the person that was responsible for creating the initial comprehensive care plan for Resident #34, the care plans should have been completed from the care area that triggered on the MDS admission assessment. She reviewed

the MDS and care plan for Resident #34 and agreed a care plan should have been implemented for nutritional status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A phone interview was conducted on 06/19/24 at 4:00 PM with the Administrator. The Administrator stated there had been staff turnover with the MDS nurses. She reported the MDS nurse was responsible for Level of Harm - Minimal harm or developing care plans and the care plan should have been initiated for Resident #34. She reported they potential for actual harm currently utilized an agency MDS nurse who worked remotely, and she planned to get an MDS nurse back in

the facility as soon as possible. Residents Affected - Some 41387

5. Resident #16 was admitted to the facility on [DATE REDACTED] with diagnoses including stroke.

Physician's orders dated 4/26/2024 included an order for Xarelto (an anticoagulant medication that prevents or break down blood clots) 20 milligrams (mg) via gastrostomy tube (G-Tube) in the evening for anticoagulation.

Resident #16's April 2024 Medication Administration Record (MAR) recorded Xarelto 20 mg was administered 4/27/2024, 4/28/2024 and 4/29/2024.

Nursing documentation dated 4/29/2024 at 8:25pm reported Resident #16 was coughing up blood and bleeding profusely from the nose. Emergency Medical Services (EMS) was called to transport Resident #16 to the hospital.

Resident #16 was discharged to the hospital on 4/29/2024 and was readmitted to the facility on [DATE REDACTED].

The 5-day admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #16 was severely impaired cognitively. The Resident #16's MDS was not coded for receiving anticoagulants.

Resident #16's comprehensive care plan dated 5/15/2024 did not include a focus for the use of anticoagulants.

Resident #16's MAR from 5/9/2024 through 6/13/2024 revealed Resident #16 received Xarelto 20 mg as ordered.

On 6/19/2024 at 11:19 am in a phone interview with the Remote MDS Nurse, she explained she was responsible for completing the comprehensive care plans after completing the MDS assessment. She stated based on the physician's order and documentation of administration of the Xarelto daily, the use of anticoagulants should have been included on the comprehensive care plan for Resident #16. She said it was

an oversight on her part.

On 6/19/2024 at 10:22 am in a phone interview with the Director of Nursing (DON), she explained the Remote MDS nurse or MDS Nurse at the facility was responsible for updating Resident #16's comprehensive care plan to include the use of anticoagulants and stated Resident #16 should have been care planned for

the use of anticoagulants. The DON explained due to resignations of previous MDS nurses since March 2024 and a back log of MDS assessments to complete, the MDS nurses were unable to dedicate sufficient time in developing a comprehensive care plan for Resident #16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 6/19/2024 at 12:25 pm in a phone interview with the Administrator, she stated the Director of Nursing was responsible to ensure the MDS nurses completed Resident #16's comprehensive care plan to included Level of Harm - Minimal harm or anticoagulants. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35173 potential for actual harm Based on observations, record review, and resident, staff, and Wound Care Physician's interviews the facility Residents Affected - Some failed to 1) perform daily wound care treatments to a non-pressure diabetic foot ulcer and implement a hind off-loading boot (a specific boot to reduce pressure on a specific part of the foot to allow a wound to heal) according to the Wound Care Physicians' orders for 1 of 3 residents (Resident #50) observed for wound care; and 2) follow physician orders to change an intravenous (IV) site every 3 days and to provide an intervention to establish IV access for a resident ordered to receive long term antibiotic therapy for 1 of 1 resident reviewed for IV medication administration (Resident #419).

Findings included:

1. Resident #50 was admitted to the facility on [DATE REDACTED]. Diagnoses included right below the knee amputation, peripheral vascular disease, left leg cellulitis, and diabetic foot ulcer.

The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed resident was cognitively intact and demonstrated no behaviors. Resident #50's was not coded as having a pressure ulcer, venous and arterial ulcer or as having a diabetic foot ulcer.

Review of the care plan updated on 05/09/24 revealed Resident #50 had a plan of care for diabetes mellitus with interventions to include, in part, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, and a plan of care for potential pressure area related to decreased mobility and peripheral vascular disease with interventions ton include monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs or symptoms of infection to physician and weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and other notable changes or observations.

Review of the wound treatment assessments revealed the following measurements and wound orders for the diabetic wound of the left heel for Resident #50:

On 04/30/24 the measurements to the left heel were recorded as 2.0 X 2.0 X 0.2 centimeters (cm) with indication the wound was improving. The treatment was silva sorb gel (antimicrobial agent), and xeroform (a pad applied to a wound to promote healing and protect the wound from harm) and wrap with kerlix.

.

On 05/07/24 the measurements to the left heel were recorded as 2.6 X 2.6 X 0.2 (cm) with indication that the wound was unchanged. The treatment was to apply Medi honey (helps prevent bacteria from growing), silver alginate (antimicrobial) and cover with gauze daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of the Wound Care Physicians' wound evaluation and management summary for diabetic wound of left foot dated 05/20/24 revealed the measurements to the left heel were recorded as 2.8 X 2.8 X 0.3 (cm) Level of Harm - Minimal harm or with 40% slough and 60 % granulation tissue (healthy tissue) with a surface area of 7.84 (cm). The note potential for actual harm indicated the wound was surgically debrided at this time and as a result of the procedure the wound bed decreased from 40 percent to 10 percent. The recommendations were to order a hind off-loading boot and Residents Affected - Some apply Santyl (helps remove dead skin tissue and aides in wound healing) with xeroform and cover with gauze daily.

A review of the physician's orders written on 05/21/24 revealed to cleanse wound with normal saline, apply Santyl with xeroform and secure with gauze daily. There was no order for a hind off-loading boot to the left heel wound.

Review of the Treatment Administration Record for May 2024 revealed on 05/25/24, the wound treatment order was not signed off as evidenced by nursing initials or a check mark. Additionally, there was no order on

the Treatment Administration Record for a hind off-loading boot to left heel wound.

Record review revealed there was no documentation to support the dressing to the left heel wound was changed on Saturday 05/25/24.

Review of the Wound Care Physicians' wound evaluation and management summary for diabetic wound of left foot dated 05/27/24 revealed the measurements to the left heel were recorded was 3.0 x 2.2 X 0.1 (cm) with 100 % granulation tissue (healthy tissue) with a surface area of 6.60 (cm). The note indicated the wound was improving as evidenced by decreased surface area. A recommendation for a hind off-loading boot was indicated.

An interview was conducted with Unit Manager (UM) #1 on 06/14/24 at 1:17 PM. UM # 1 revealed she was assigned to the hall Resident #50 resided on 05/25/24. She stated if a there was nothing charted in the treatment administration record on 05/25/24 then it meant that the treatment was not done. UM #1 reported

she was not aware of an order for a hind off-loading boot for Resident #50.

Review of the Wound Care Physicians' wound evaluation and management summary for diabetic wound of left foot dated 06/03/24 revealed the measurements to the left heel were recorded as 3.6 X 2.8 X 0.1 (cm) with indication the wound was unchanged. The treatment was changed to cleanse left heel with normal saline, apply calcium alginate and Medi honey and wrap with gauze daily. The note indicated the wound was surgically debrided at this time and as a result of the procedure the wound bed decreased from 20 percent to 0. The recommendation was to order a hind off-loading boot.

A review of the physician orders dated 06/03/24 revealed an order to cleanse left heel with normal saline, apply calcium alginate and Medi honey and wrap with gauze daily.

Review of the Treatment Administration Record for June 2024 revealed on 06/09/24 the wound treatment order was not signed off as evidenced by nursing initials or a check mark.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 An interview and observation was conducted with Resident #50 on 06/10/24 at 1:00 PM. Resident #50 reported he was never given an off loading boot and when he inquired about it to the Director of Nursing she Level of Harm - Minimal harm or stated she did not know how to order the boot. Resident #50 also reported that in May, during the holiday potential for actual harm weekend, his dressing to his left heel did not get changed. At this time, Resident #50 revealed the dressing to his left heel and added, the nurse had not changed the dressing since 06/08/24. The wound dressing was Residents Affected - Some dated 06/08/24.

Observation of the wound dressing to the left heel on Resident #50 with the Wound Treatment Nurse was conducted on 06/12/24 at 2:30 PM. The wound was not measured at this time. There were no signs or symptoms of infection such as odor or drainage. Resident #50 had no complaints of pain.

An interview was conducted with the Wound Treatment Nurse on 06/12/24 at 2:30 PM. The Wound Treatment Nurse stated the wound to Resident #50's left heel was debrided by the Wound Care Physician

on 06/03/24 and the treatment was changed. She stated whenever a wound was debrided, the wound may appear that it was worsening with increased measurement size which was due to the debridement opening up the wound bed.

An interview was conducted with Unit Manager #2 on 06/14/24 at 2:00 PM. UM #2 reported she was assigned to Resident #50 on 06/09/24 and she should have changed the dressing as ordered to his left heel.

She stated she was the nurse overseeing the medication aide and it was her responsible to do wound care since the medications aides were not allowed to perform wound care. Unit Manager #2 reported she was not aware of an order for a hind off loading boot for his left heel.

A phone interview was conducted with the previous Wound Care Physician on 06/17/24 at 1:00 PM revealed

he was familiar with Resident #50 and his chronic heel wound. He stated he would have to refer back to his records but he stated based on what he could recall he felt that the wound was chronic and it was the same or slightly better but not getting worse. The Wound Care Physician was not able to complete the interview and stated he would return the call after he reviewed the medical record.

A follow up phone interview was conducted with the Wound Treatment Nurse on 06/17/24 at 2:11 PM. The Wound Treatment Nurse reported that when the Wound Care Physicians put in recommendations, they were considered orders and she would enter the orders into the electronic medical record. The Wound Treatment Nurse stated she was aware that Resident #50 had an order for the hind off-loading boot, but she was not sure why it was not ordered. The Wound Treatment Nurse stated the physician had classified the left heel wound as a diabetic ulcer since he was admitted to the facility and was acquired from his uncontrolled diabetes and peripheral vascular disease. The Wound Treatment Nurse added, she recalled letting the Director of Nursing (DON) know about the recommendation for the hind off-loading boot, but she did not follow up with the Director of Nursing to see what the status of the hind off-loading boot was or when it was going to be ordered.

An interview was conducted with the Director of Nursing (DON) on 06/14/24 at 5:00 PM. The DON revealed

she would expect wound treatments to be getting according to the physician's order to prevent infection or further debilitating a declining wound. The DON stated she did not know what a hind off-loading boot was and was working on trying to figure out where to order this type of boot with local wound supply companies.

A follow up call was placed to the previous Wound Care Physician on 06/18/24 at 1:57 PM. A message was left for a returned call.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of the Wound Care Physicians' wound evaluation and management summary for diabetic wound of left foot dated 06/20/24 revealed the measurements to the left heel were recorded as 2.6 X 2.1 X 0.1cm with Level of Harm - Minimal harm or a surface area of 5.46 cm. Granulation tissue was noted to be at 100% with a note indicating the wound was potential for actual harm healing as evidenced by a 45.8% decrease in surface area and 100% decrease in nonviable tissue within the wound bed and a recommendation was noted for a hind off-loading hind boot for left heel. Residents Affected - Some

A phone interview was conducted with the Nursing Supervisor on 06/26/24 at 11:00 AM. The Nursing Supervisor stated she was made aware from the Wound Treatment Nurse about 2 weeks ago that a hind off loading boot was needed for Resident #50. She stated she and the previous DON were trying to figure out what type of boot this was by researching on line with local wound supply companies because they had never heard of it. She stated she spoke to the current Wound Care Physician on 06/25/24 to clarify the order for the hind off-loading boot and this physician sent her a link as to what the boot was and where to order it.

She stated the current DON who started on 06/19/24 will be ordering the boot.

An interview with the current Director of Nursing via phone on 06/26/24 at 3:10 PM revealed she had started

on 06/19/24 and it was brought to her attention on 06/25/24 from the Nursing Supervisor that Resident #50 needed the hind off-loading boot. The DON stated it should have been ordered by the previous DON. She added, she ordered the hind off-loading boot today and it will be in the facility on 06/28/24.

A phone interview with the current Wound Care Physician on 06/27/24 at 9:30 AM revealed she had been attending the facility since 06/14/24 and she did mention to the Wound Treatment Nurse that the hind off loading boot should be ordered for Resident #50. She stated it was not a unique type of boot or difficult to find and she could not speak to as to why it took so long for the boot get ordered. The Wound Care Physician stated she sent a link to the Nursing Supervisor of where to purchase the boot. She added, not having the boot would not contribute to the wound worsening, it was ordered as a protective device. She stated despite the resident not having the boot for the past month, his wound was healing but it should be ordered and utilized to add that extra protection. Additionally, the Wound Care Physician stated Resident #50's wound dressing was ordered daily and she would expect the dressing to get changed daily for continued wound healing.

37673

2. Resident #419 was admitted to the facility most recently on 08/07/23.

Diagnoses included, in part, a sacral stage 4 pressure ulcer, and hemiplegia and hemiparesis following a stroke (cerebral infarction) affecting his dominant right side.

Review of a quarterly Minimum Data Set (MDS) assessment date 02/09/24 revealed Resident #419 had severely impaired cognition. Both upper and lower extremities on one side were impaired. He had one stage 4 pressure ulcer and one deep tissue injury that were not present on admission. He had received pressure ulcer care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The care plan for Resident #419 revised on 03/05/24 documented a focus area of antibiotic therapy. The goal was for the resident to be free of any discomfort or adverse side effects of antibiotic therapy through the Level of Harm - Minimal harm or review date. Interventions included administering antibiotic medication as ordered by the physician and to potential for actual harm monitor and document any side effects, the effectiveness, and any signs of secondary infection related to the antibiotic therapy. Residents Affected - Some 2a. The March 2024 Medication Administration Record (MAR) revealed the following physician order: Change IV (intravenous) site every day shift every 3 day(s) for infection control-Start date 03/01/24; End date 03/23/24. The MAR was coded 5 on 03/04/24 (indicating the IV site change was held) and was left blank on 03/10/24.

Review of the progress notes dated 03/04/24 revealed Agency Nurse #6 documented the IV site change was to be held and that another nurse would change the IV site the following day.

In an interview with Agency Nurse #6 on 06/26/24 at 12:10 PM she stated she was told on 03/04/24 not to change Resident #419's IV site because a Registered Nurse would be at the facility the next day and she would change the IV site. She could not remember who told her to hold the IV site change and did not know if the site had been changed the next day.

Review of the progress notes and MAR for 03/05/24 revealed no documentation that the IV site for Resident #419 had been changed.

In an interview with Nurse #5 on 06/26/24 she stated she was familiar with Resident #419 but could not remember taking care of him on 03/10/24 or changing his IV site on that date. She stated that she was not normally on his assignment, and it was too long ago to recall.

2b. Resident #419 had physician orders dated 2/23/24 for IV antibiotic daily for 4 weeks.

A progress note written by Agency Nurse #2 on 3/15/24 at 3:38 pm documented Resident #419's IV had infiltrated (came out of the vein and leaked fluid into the surrounding tissue) and she was not able to give the 1:00 pm dose of antibiotic. She made two unsuccessful attempts to restart the IV.

A progress note written by Nurse #13 on 03/16/24 at 12:28 am documented she attempted one time to place

an IV in Resident #419's left forearm and was unsuccessful.

Progress notes written by Medication Aide #5 on 03/16/24 at 11:24 am and 12:14 pm documented Resident #419 did not receive his antibiotic medications because he did not have an IV.

A progress note written by Agency Nurse #2 on 03/17/24 at 4:36 pm documented an IV site was acquired and the antibiotics restarted. The MAR for 03/17/24 indicated Resident #419's antibiotics were not documented with a check mark that would have indicated the medications had been administered.

A progress note written by Agency Nurse #3 on 03/20/24 at 6:49 pm documented Resident #419 ' s IV had not been working since the beginning of the shift. She attempted to restart the IV three times and the charge nurse tried to restart the IV two times, but all 5 attempts were unsuccessful.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview with Nurse #3 on 6/12/24 at 1:55 PM she stated while she was working the IV site stopped working and she tried to restart the IV but could not. She commented that Resident #419 was a hard stick Level of Harm - Minimal harm or (meaning it was difficult to start his IV). Another agency nurse on duty tried and could not get the IV started. potential for actual harm She passed on in report to the next nurse the unsuccessful attempts to restart the IV. She noted the nursing supervisor on duty also tried to start the IV and could not. She did not know the names of the other two Residents Affected - Some nurses but thought they were also from an agency. She cared for Resident #419 on 03/19/24 and 03/20/24.

A progress note written by Agency Nurse #2 on 03/22/24 at 3:51 pm documented she had tried to start an IV for Resident #419, but the attempt was unsuccessful.

In an interview with Agency Nurse #2 on 6/12/24 at 1:50 PM she stated she was not sure if she had tried to restart his IV access or not. She cared for Resident #419 on 03/15/24 and 03/22/24.

A progress note written by Nurse #13 on 03/23/24 documented Resident #419 did not receive his antibiotics because he had no IV access.

In an interview with the Wound Care Nurse on 06/12/14 at 12:30 PM she stated the Nurse Practitioner (NP) was aware the IV was out. She noted the NP was supposed to come to the facility and restart the IV. She cared for Resident #419 on 03/23/34.

In an interview with Nurse #20 on 07/01/24 at 10:10 am she stated she had cared for Resident #419 on 03/16/24, 03/19/24, and 03/21/24. She recalled when she assessed him to start an IV site, she could not find

a vein.

Multiple unsuccessful attempts were made to contact the NP on 06/12/14 at 1:48 PM and 3:36 PM. She had been employed at the facility in March 2024. An additional attempt was made on 06/13/24 at 3:07 PM with no response. Other attempts were made to contact the NP by different surveyors on the team throughout the survey week with no response.

Multiple unsuccessful attempts were made on 06/12/14 at 1:50 PM and 3:33 PM to contact the physician employed at the facility in March 2024. An additional attempt was made on 06/13/24 at 3:00 PM with no response. Other attempts were made to contact the physician by different surveyors on the team throughout

the survey week with no response.

In an interview with the current Agency DON (Director of Nursing) on 06/12/24 at 1:05 PM she stated she became employed at the facility on 03/25/24. She commented if she had been employed when the facility nurses could not establish IV access, she would have first tried to start the IV herself and if unsuccessful she would have called the provider, obtained an order for a PICC line and would have sent the resident out to have IV access established within 24 hours of the first unsuccessful attempt to re-establish IV access.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32968 potential for actual harm Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to assess, obtain Residents Affected - Few physician orders for treatment, and communicate about the new pressure ulcer so assessments and treatments could be provided for 1 of 5 residents reviewed for pressure ulcers (Resident #119).

Findings included:

Resident #119's Hospital admission note dated 03/02/24 revealed resident with pressure ulcer of coccygeal region that was present on admission.

Resident #119 was admitted from the hospital to the facility on [DATE REDACTED]. The diagnoses included diabetes, congestive heart disease, end stage renal disease, atrial fibrillation, and hypertension.

Review of the head-to-toe skin assessment for Resident #119 dated 04/04/24 done by Nurse #2, identified and documented a Sacrum - small, reddened area to bony prominence, pressure absorbent bandage in place.

A nursing note dated 04/05/24 at 2:37 AM by Nurse #10 revealed Resident #119 admitted to facility via stretcher from hospital during day shift. Resident was alert and oriented with some confusion noted and was able to verbalize needs. She had an open area noted to bony prominence of coccyx, and area was cleansed with normal saline and new dressing applied.

A telephone interview was conducted with Nurse #10 on 06/12/24 at 10:35 AM. Nurse #10 stated she completed the initial admission skin assessment for Resident #119 on 04/04/24. Nurse #10 explained she noticed Resident #119 had a dressing in place from the hospital on her coccyx covering what looked like an open split skin area on her buttock crack near the sacrum. There was no drainage or odor. She said she removed the old dressing, cleaned the site with normal saline. She also said she did not recall documenting

a description of her observation, but she was certain she informed the day nurse of her observation and dressing change and let the wound treatment nurse know of the site.

A nursing note dated 04/05/24 at 1:36 PM by Nurse #1 revealed nurse went to assess Resident #119's skin, but she had left facility to go to dialysis and would be back later this PM.

Review of the April 2024 Treatment Administration Record (TAR) for Resident #119 revealed the resident received treatment Calmoseptine to buttock with each incontinent episode, apply every day at night shift and to start 04/06/24 at 7:00 PM. The TAR had no documented treatment for the coccyx pressure ulcer.

The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #119 had no cognitive impairments. She required substantial/maximal physical assistance with bed mobility, transfers, and activities of daily living. She was always incontinent of bowel and frequently incontinent of bladder.

Resident #119 was discharged to her home on 04/10/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 An interview was conducted on 06/12/24 at 10:00 AM with the Director of Nursing (DON). The DON stated Nurse #119 documented an observation of an open area noted to bony prominence of coccyx and she Level of Harm - Minimal harm or cleaned the area with normal saline and applied a new dressing. She acknowledged there was no potential for actual harm documenation about Resident #119's coccyx ulcer from admission 04/04/24 through discharge on 04/10/24.

Residents Affected - Few An interview was conducted on 06/12/24 at 3:45 PM with Unit Manager #2 (previous treatment nurse). The Unit Manager stated on 04/05/24 the day nurse who received report from Nurse #10 should have reported Resident #119's sacral pressure ulcer to her for evaluation and possible treatment which she did not.

An interview was conducted on 06/13/24 at 10:50 AM with the Administrator. She said it was her expectation that Resident #119's admission coccyx pressure ulcer should have been identified, treated, and tracked more closely by nursing staff.

An interview was conducted on 06/14/24 at 10:20AM with the Nurse Practitioner (NP). She stated it was her expectation that on 04/05/24 the day nurse assigned to Resident #119 should have reported the coccyx pressure ulcer to the wound treatment nurse that same morning it was reported to her and did not. The NP said all nursing staff are responsible for reporting all wounds timely to the treatment nurse so she can obtain appropriate orders and start treatment. NP stated it was important to her and the treatment nurse to know what wounds were in the facility and what treatments were being utilized, which had not happened in this case.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35173

Residents Affected - Few Based on observations, record review, resident and staff interviews, the facility failed to supervise a dependent resident (Resident #50) when he was left alone in the shower room on the shower chair and waited for staff to answer the call light and provide assistance for 1 of 7 residents reviewed for accidents.

Findings included:

Resident #50 was admitted to the facility on [DATE REDACTED]. Diagnoses included right below the knee amputation with prothesis, coronary artery disease, high blood pressure, chronic kidney disease, and congestive heart failure.

The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed resident was cognitively intact and demonstrated no behaviors. He required supervision with one person physical assistance with transfers, had impairment one side to lower extremity, used a wheelchair and had limb prosthesis. Resident #50 required partial to moderate assistance with showering and bathing, lower body dressing below the waist, getting in and out of shower, and transferring from chair to wheelchair. He required substantial to maximal assistance with taking off and putting on footwear.

Review of Resident #50's care plan dated 10/23/23 revealed a plan of care was in place for resident being independent on meeting emotional, intellectual, and social needs, however, at this time he is dependent on staff to meet some physical needs due to limitations. Interventions included, in part, to converse with resident while providing care, ensure adaptive equipment that the resident needs is provided and present and functional. Additionally, a plan of care was in place for at risk for falls related to gait and balance problems with an interventions to include, in part, call light within reach and requires a prompt response to all requests for assistance.

Review of the camera footage timeline on an incident report dated 05/17/24 revealed the following:

10:42 AM Resident #50 entered the shower room. NA #8 followed Resident #50 and entered the shower room.

10:46 AM Nurse Aide #8 exited the shower room

10:48 AM Nurse Aide #8 reentered the shower room

10:49 AM Nurse Aide #8 exited the shower room

11:00 Call light in shower room sounds

11:16 AM Nurse Aide #8 entered the shower room

11:20 AM Nurse Aide #8 and Resident #50 exited shower room and went to Nurse #9 and were telling her something.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An interview with Resident #50 on 06/14/24 at 1:00 PM revealed on 05/17/24, he was left unattended in the shower for over 15 minutes. He stated he was on the smoking porch and stated he wanted to get a shower Level of Harm - Minimal harm or early on this day because he had family coming. Resident #50 stated Nurse Aide (NA) #8 said he was not on potential for actual harm her assignment, but that she would get him started in the shower. Resident #50 stated NA #8 took him to the shower and assisted with transferring him to the shower chair from his wheelchair and assisted him with Residents Affected - Few getting undressed, removed his prosthetic leg and turned the shower on. Resident #50 stated he proceeded to bathe himself and washed his hair. He used the call bell to alert for help when he was done. He stated no one came after a few minutes so he turned the water again to keep himself warm and washed himself again while waiting for someone to answer the call bell. He stated he then started to yell for someone to come and help him, but no one came. Resident #50 stated the shower chair did not have wheels like his wheelchair so

he was not able to move it easily, but he was able to reach a towel and dry off and reached his prosthetic leg and put it on. He stated he continued to yell, but still no one came. Resident #50 stated he then attempted to transfer himself from the shower chair to the wheelchair but he banged his leg and was not able to transfer himself safely. Resident #50 stated after about 15 minutes, NA #8 finally came back and helped him get out of the shower chair and transferred him to his wheelchair.

An interview was conducted NA #8 on 06/14/24 at 2:35 PM. NA #8 reported she was on the smoking porch with Resident #50, and he reported he wanted a shower. He stated his aides from the 100 hall were busy so

she told him she would get him in the shower. NA #8 stated she was assigned to the 200 hall, but she helped transfer Resident #50 to a shower chair from his wheelchair and assisted with removing his clothes and his prosthetic leg. She then turned on the water and he began to take his shower. NA #8 stated that she and Nurse #7, who was also assigned to the 200 hall, told Nurse #9 who was assigned to the 100 hall that they were going to the store to get soap which was located across the street and only minutes away. NA #8 stated they were back within 15 minutes or less and when they came back, they saw the shower light going off and Nurse #9 was sitting at the computer at the nursing station. NA #8 stated she went into the shower room and saw Resident #50 was still in the shower. She assisted him with getting dressed and brought him out of the shower room. She stated Resident #50 wanted to know why his aides left him in the shower room. NA #8 stated she was told by the Director of Nursing after it all happened that if she could not stay with a resident while in the shower, then do not give the shower to the resident and to leave it to the assigned nurse aides to do the shower. NA #8 stated she should not have left Resident #50 alone in the shower because no resident should be left alone while they were getting a shower for safety reasons. She stated Resident #50 could wash and dress himself, but he needed assistance with dressing, and he needed assistance pulling himself out of the shower chair to his wheelchair. NA #8 added, Resident #50 needed someone there to get him out of the shower and he was not safe to be left alone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An interview was conducted with Nurse #7 on 06/13/24 at 11:45 AM. Nurse #7, who was not assigned to Resident #50, reported on 05/17/24, Resident #50 was out on the smoking porch and stated he had family Level of Harm - Minimal harm or coming in to see him today and he wanted a shower and NA #8 said she would give him one. NA #8 assisted potential for actual harm Resident #50 in the shower. She stated after he was in the shower, she and NA #8 told Nurse #9 that they were leaving the facility to go to the store across the street to get soap and that Resident #50 was in the Residents Affected - Few shower and for her to let his aides know so they could get him out. Nurse #7 reported they were at store for about 15 minutes and when they came back, the call light was on to the shower room and Nurse #9 was sitting at the nurse's station not answering the light. Nurse #7 stated NA #8 went to the shower room to assist Resident #50 out of the shower. Nurse #7 stated Nurse #9 did not tell the aides that were assigned to Resident #50 that he was in the shower and she did not answer the light when it rang. Nurse #7 stated anytime any resident was getting a shower, the nursing staff was to supervise the resident while in the shower to prevent any accidents and she should have made sure someone was supervising Resident #50

before she left for the store.

An interview was conducted with Nurse #9 via phone on 06/13/24 at 2:19 PM. Nurse #9 reported she was

the nurse assigned to the 100 hall on 05/17/24 where Resident #50 resided. She stated Resident #50 was upset about being left in the shower room and that no one was answering the call light to assist him. She stated Resident #50 told her that NA #8 had put him in the shower and left. Nurse #9 stated she had learned from NA #8 that she and Nurse #7 left the building to go to the store, but it was not until they returned. Nurse #9 stated neither NA #8 nor Nurse #7 reported to her that Resident #50 was in the shower or that they were going to the store. Nurse #9 stated she did not recall hearing the call light going off.

An interview was conducted with NA #4 via phone on 06/18/24 at 10:39 AM. NA #4 reported she had worked at the facility as agency nurse aide for about 8 weeks. She stated she was assigned to Resident #50 on the 100 hall on 05/17/24. NA #4 reported she did not what had actually happened on 05/17/24 but was told someone put Resident #50 in the shower, but they did not inform her or NA #5 who was also assigned to Resident #50. NA #4 reported Resident #50 and Nurse #9 approached her and NA #5 while they were doing resident care for another resident and Resident #50 was yelling at us for leaving him in the shower, but they had no idea he was even in the shower and did not hear the call light because they were in another room down another hall. NA #4 stated whenever she gave Resident #50 a shower, she would assist him getting undressed, removing his prosthetic, and transferring him from the wheelchair to the shower chair. She stated

she would provide privacy while he would bathe himself, but that in order to provide safety for the resident,

she would not leave the shower area and leave the resident unattended. She stated no resident should be left in the shower area alone because they could fall and hurt themselves.

An interview was conducted with the Director of Nursing (DON) on 06/14/24 at 11:00 AM. The DON reported that a nursing staff member should always be with a resident whenever they were getting a shower. The DON stated she did not know NA #8 and Nurse #7 left the building and it was not okay for them to leave without telling anyone. She stated her expectation of nursing staff was that residents should not be left in the shower alone because of the potential for an accident. The DON added Resident #50 had a mobility risk due to his impairment and he required supervision while in the shower.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45711 potential for actual harm Based on record review, staff, Registered Dietitian and Facility Physician interviews, the facility failed to Residents Affected - Some obtain physician ordered weekly weights for 4 of 6 residents reviewed for nutrition and wound care evaluation (Resident #36, Resident #38, Resident #219, Resident #52) and failed to address a Registered Dietitian recommendation for a medication to stimulate appetite for 2 of 6 residents reviewed for nutrition (Resident #36, Resident #38).

Findings included:

1. Resident # 36 was admitted on [DATE REDACTED] with diagnoses which included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and diabetes.

Resident # 36's electronic health record included a 2/8/24 physician order for weight on admission then weekly for 3 weeks (4 weights total); then monthly or as specified by the physician.

Resident # 36's weight record contained the following:

2/9/2024 10:13 AM 118.7 pounds (lbs.)

2/16/2024 No weight recorded.

2/23/2024 No weight recorded.

3/3/2024 7:06 PM 121.0 lbs.

A 3/12/24 Registered Dietitian (RD) note indicated Resident #36 was reviewed. Resident # 36 consumed 25-100 percent of a carbohydrate-controlled diet. RD recommended providing supervision and cueing with meals and a fortified foods diet.

A physician order dated 4/4/24 indicated weekly weights for weight monitoring and regular fortified food diet.

A 4/9/2024 Registered Dietitian (RD) note indicated Resident #36 was reviewed for weight loss. The note stated resident's current weight on 4/5/24 was 98 lbs. Resident #36's weight was 121 lbs. on 3/3/24 which was a weight loss of 19 percent in 1 month. The RD indicated Resident #36 consumed 0-75% of a mechanical soft diet with supervision. The following recommendations were made obtain a reweigh to verify current weight, weekly weight x 4 weeks, medication to increase appetite and add protein supplement three times per day.

Resident #36's weight record indicated the following weights:

4/5/2024 98.0 Lbs.

4/12/2024 No weight recorded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 4/19/2024 No weight recorded.

Level of Harm - Minimal harm or 4/20/2024 98.2 Lbs. potential for actual harm 4/27/2024 No weight recorded. Residents Affected - Some 5/4/2024 106.4 Lbs.

5/11/2024 No weight recorded.

5/18/2024 No weight recorded.

5/25/2024 No weight recorded.

6/1/2024 No weight recorded.

6/9/2024 No weight recorded.

A 5/7/2024 Registered Dietitian note stated in part Resident # 36's weights were reviewed with a gain of 8. 5% in 1 month and a loss of 10.3% in 3 months. The note did not indicate a reason for the weight fluctuations.

Resident # 36's care plan revised on 5/14/24 indicated a nutrition at risk problem related to weight loss with interventions to obtain weights per orders, fortified foods, and monitor intake and record.

Resident # 36's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed resident had a severe cognitive impairment, weight of 106 lbs. and was on a physician prescribed weight gain program.

An interview was conducted on 6/12/24 at 2:15 PM with the Agency Director of Nursing (DON). The DON stated weights were not consistently obtained. The DON stated the facility required a better system for obtaining weights and addressing nutritional recommendations. The DON stated she expected staff to obtain weights on admission and weekly for 3 weeks following admission. The DON further indicated she expected physician ordered weights would be obtained. Without the monitoring of weights, the RD and physician are not able to evaluate the root cause of weight changes in the residents.

An interview was conducted on 6/12/24 at 2:45 PM with the Registered Dietician (RD). The RD stated weights were supposed to be obtained within the first ten days of the month and that was not being done.

The RD stated she informed the Administrator and DON several times over the past 3 months that resident weights were a problem, were not being obtained and this had not improved. The RD indicated Resident # 36's weights were not obtained weekly on admission and as ordered. The RD stated weights were necessary to make recommendations, evaluate the resident's nutritional needs and evaluate current interventions. Without accurate weights and obtaining weekly weights as ordered, the RD stated it was difficult to determine the cause of Resident # 36's weight changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 A follow up interview was conducted with the Director of Nursing (DON) on 6/14/24 at 4:10 PM. The DON stated weights were not obtained timely and accurately. The DON stated she was hired through an agency a Level of Harm - Minimal harm or few months ago and had not implemented a process for obtaining weights yet but indicated it was an potential for actual harm important part of the resident's care and was necessary to evaluate the resident's condition.

Residents Affected - Some An interview was conducted with the Facility Physician on 6/18/24 at 1:24 PM. The Facility Physician stated

she started in the position on 6/7/24 and indicated monitoring of weights was the facility's responsibility and was important to evaluate the resident's nutritional status. The Facility Physician further stated weights were to be obtained as ordered and the recommendations made by the Registered Dietitian should be evaluated and addressed. The Facility Physician stated Resident #36's weights should have been obtained as ordered and the Registered Dietitian recommendations should have been addressed.

Attempts were made to interview the previous Physician who was in the position at the facility until 6/6/24. Messages were left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received.

Attempts were made to interview the previous Nurse Practitioner (NP) who was in the position at the facility until 6/6/24. Messages were left on 6/12/24 at 3:36 PM and 6/13/24 at 3:07 PM with no return call received.

2. Resident #38 was admitted on [DATE REDACTED] with diagnosis which included stroke and dementia.

Resident # 38's care plan dated 12/15/23 indicated a problem of at nutritional risk for weight loss with the following interventions included physician or Nurse Practitioner to evaluate for failure to thrive, fortified foods, protein supplement and consult with physician regarding order for vitamin or other appetite stimulant and RD consult.

Resident # 38's weight record indicated:

12/30/23 91.2 pounds (lbs.).

1/8/2024 89.0 lbs.

1/21/2024 102.0 lbs.

2/5/2024 105.0 lbs.

3/3/2024 89.5 lbs.

Resident # 38's physician orders indicated an order for regular diet with fortified foods.

A 3/12/24 Registered Dietitian progress note indicated Resident # 38 was reviewed for weight loss trend. A weight of 113.5 Lbs. was recorded on 9/6/23 which indicated a 21.3 percent weight loss over 6 months. Recommendation was made to obtain a reweigh due to weight loss and obtain weekly weight for 4 weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Resident # 38's physician orders indicated a 3/18/24 order for weekly weights for weight monitoring until 04/15/2024. Level of Harm - Minimal harm or potential for actual harm Resident # 38's weight record indicated:

Residents Affected - Some 3/19/2024 89.0 lbs.

3/26/24 no weight recorded.

4/5/2024 93.0 lbs.

4/12/24 no weight recorded.

4/20/2024 83.0 lbs.

Resident # 38's 4/22/24 quarterly Minimum Data Set (MDS) indicated a weight of 83 lbs. and weight loss of 5 percent or more in the last month or loss of 10 percent in the last 6 months.

An RD progress note dated 4/23/2024 indicated Resident # 38 was reviewed for weight loss. Current weight 4/20/24 83 lbs. A weight of 113 lbs. on 10/11/23 indicated a loss of 18.6 percent over 3 months, and a loss of 26.5 percent over 6 months. Resident # 38 consumed 0-50 percent of a regular fortified foods diet and received a protein supplement. Recommendations included: medication to help increase appetite, obtain weekly weights for 4 weeks and evaluate for failure to thrive and protein calorie malnutrition due to weight loss and decreased appetite. The RD did not indicate a root cause analysis of Resident # 38's weight loss.

Resident # 38's physician orders revealed no order dated 4/23/24 or later was entered for weekly weights.

Resident # 38's physician orders revealed no order dated 4/23/24 for a medication to help increase appetite.

A physician note dated 5/3/24 indicated Resident # 38's weight loss and the 4/23/24 Registered Dietitian recommendation for medication to increase appetite were not addressed.

Resident # 38's weight record indicated:

5/2/2024 92.0 lbs.

5/9/24 no weight recorded.

5/17/24 no weight recorded.

5/24/24 no weight recorded.

Review of a Nurse Practitioner progress note dated 5/20/24 indicated resident's weight and the 4/23/24 Registered Dietitian recommendation for medication to increase appetite were not addressed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Resident # 38's electronic health record included a Registered Dietitian progress note dated 5/30/2024. The progress note indicated Resident # 38 was reviewed for weight loss trend. Current weight 5/2/24 92 lbs. Level of Harm - Minimal harm or potential for actual harm Weight on 11/2/23 was 112 lbs. which indicated a 12.3 lbs. weight loss in 3 months and 17.8 percent loss over 6 months. Recommendations included: medication to help increase appetite and physician evaluation Residents Affected - Some for failure to thrive or protein calorie malnutrition diagnosis.

Resident #38's physician orders revealed no order dated 5/30/24 or later was entered for a medication to help increase appetite.

Resident #38's electronic health record revealed no physician progress note addressing the 5/30/24 Registered Dietitian recommendation for a medication to increase appetite or evaluation for diagnosis of failure to thrive or protein calorie malnutrition.

Attempts were made to interview the previous Physician who was Medical Director until 6/6/24. Messages were left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received.

Attempts were made to interview the previous Nurse Practitioner (NP) who was employed at the facility until 6/6/24. Messages were left on 6/12/24 at 3:36 PM and 6/13/24 at 3:07 PM with no return call received.

An interview was conducted on 6/12/24 at 2:45 PM with the Registered Dietitian (RD). The RD stated weights were to be obtained within the first ten days of the month and that was not being done. The RD indicated she had a concern regarding the accuracy of the weights and reweights were not obtained when there was a weight change. The RD stated she informed the Administrator and the Director of Nursing several times over the past 3 months that resident weights were not obtained and there was no improvement. The RD indicated Resident #38's weights were not obtained as ordered or as recommended and this made it difficult to make recommendations, evaluate the resident's nutritional needs and evaluate current interventions. The RD stated that the nutritional recommendations were not addressed for Resident #38.

An interview was conducted with Unit Manager #2 on 06/14/24 at 2:00PM. Unit Manager #2 stated she was responsible for ensuring the weekly and monthly weights were obtained. She stated the order for weekly weights was entered into the computer system for all new admissions. She stated when she selected the order type, she did not select Medication Administration Record (MAR),, but instead selected other orders, no documentation required. She stated by selecting the other orders option, the order would not carry over to

the MAR to inform the nursing staff that a weekly weight was due. She stated the weekly weight order also did not populate on the weekly weight order report and that was why the weights were not done. Unit Manager #2 stated she gave a list of weights that were needed to the Nursing Assistants (NAs), but she did not follow up with them to ensure they were obtained.

A follow up interview was conducted with the Agency Director of Nursing (DON) on 6/14/24 at 4:10 PM. The DON stated weights were not being done due to a breakdown in the process. The DON stated she expected weights would be obtained timely and accurately. The DON further indicated she was hired through an agency, had only been in the position of DON at the facility for a few months and had not yet implemented a process to obtain weights. The DON indicated nutrition was an important part of the resident's care and weights were necessary to evaluate the resident's condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 An interview was conducted with the Facility Physician on 6/18/24 at 1:24 PM. The Facility Physician stated

she had only been in the position since 6/7/24. The Facility Physician stated obtaining weights was the Level of Harm - Minimal harm or facility's responsibility and was important to evaluate the resident's nutritional status. The Facility Physician potential for actual harm further indicated that weights were to be obtained as ordered and the recommendations made by the Registered Dietitian should be evaluated and addressed. The Facility Physician stated Resident #38's weight Residents Affected - Some changes and the recommendation for a medication to stimulate appetite should have been evaluated and addressed.

40044

3. Resident #219 was admitted to the facility on [DATE REDACTED] with diagnosis including cellulitis of the left lower limb and diabetes.

A physician's order dated 05/22/24 for Resident #219 revealed to obtain weight on admission then weekly for three weeks, then monthly or as specified by the physician.

A physician's order dated 05/28/24 for Resident #219 revealed to obtain weekly weights for nutrition and wound evaluation.

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] revealed Resident #219 was cognitively intact. She received wound care and a therapeutic diet. The weight was 191.8 lbs. (pounds). There was no weight loss or gain. The care area assessment indicated to initiate a care plan with interventions for nutritional status.

Review of Resident #219's electronic medical record from admission on 05/22/24 through 06/19/24 revealed

an admission weight recorded on 05/22/24. The weight was 191.8 lbs. (pounds). There were no other weights recorded.

During an interview on 06/14/24 at 10:23 AM Nurse Aide #3 stated she recently started working in the facility and was the assigned Nurse Aide for Resident #219. She stated she was given a list at the beginning of the month of residents that needed monthly weights. She stated if a weekly or daily weight was needed the nurse would let her know. She stated she had not been told to obtain Resident #219's weight. She indicated

she had not received a list of residents who needed weights so far this month.

During an interview on 06/14/24 at 10:53 AM Nurse #6 stated she was routinely assigned to the 400 hall and to Resident #219. She stated the nurse aides obtained monthly weights and the weights were given to the nurse to enter into the electronic medical record. She stated she was not aware Resident #219 had an order for weekly weights because nothing populated in the electronic medical record to notify her that a weekly weight was needed for Resident #219.

During an interview on 06/14/24 at 11:30 AM Nurse Aide #4 stated the unit manager gave them a list of names each month of residents that needed weights. She stated they received the list of names at different times during the month. At times she would get the list of names at the beginning of the month, other times

she received the list of names for weights later in the month. She stated she didn't know which residents received weekly weights and the nurse would inform her if a weight was needed. She stated when weights were obtained each month the weights were given to the assigned nurse and the nurse entered the weight into the electronic medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 06/14/24 at 11:30 AM Nurse Aide #5 stated the unit manager gave them a list of names each month of residents that needed weights. She stated she didn't know which residents received Level of Harm - Minimal harm or weekly weights and the nurse would inform her if a weight was needed. She indicated when weights were potential for actual harm obtained each month the weights were given to the assigned nurse and the nurse entered the weight into the electronic medical record. She stated she didn't typically work the 400 hall and was not aware Resident #219 Residents Affected - Some had orders for weekly weights.

During an interview on 06/14/24 at 12:30 PM the Registered Dietician stated there had been issues with getting weights. She stated the Director of Nursing, and the Administrator were aware of the issue, and it was being discussed in their Quality Assurance meetings. She reported that Resident #219 was admitted on [DATE REDACTED] with cellulitis and an abscess on the groin. She received daily wound care to the area and received nutritional supplements three times a day. She reported Resident#219's BMI (body mass index) was elevated, and the weekly weights were ordered to evaluate her nutrition for wound assessments. She stated

she was aware the weekly weights were not getting done and had reported this to Administration. She expected weights to be obtained according to the physician's order.

During an interview on 06/14/24 at 1:18 PM the Wound Nurse indicated she was not aware Resident #219 had an order for weekly weights to assess her nutritional needs for wound evaluation. She stated Resident #219 was followed by the wound care physician weekly in the facility and the wound was improving. She indicated the weekly weight order was not on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) and therefore she was not aware of the order.

During an interview on 06/14/28 at 2:00 PM Unit Manager #2 indicated she had not followed up on weights.

She stated she printed a list of names each month and gave the list to the nurse aides. She stated she did not follow up to ensure weights were obtained and reported to the nurses each month because the Registered Dietician reviewed weights. She indicated that she had not given the list of resident names to the nurse aides to obtain weights for the current month and she was not aware that Resident #219 had orders for weekly weights.

During an interview on 06/14/24 at 4:08 PM the Director of Nursing (DON) stated monthly weights were to be done by the 5th of each month and weekly weights should be obtained on the first day of the week. She indicted she was aware that obtaining weights was an issue. She reported staff responsible for obtaining weights had developed bad habits and there had been no accountability. She stated more work was needed and staff education would be provided.

A phone interview was conducted with the Physician on 6/18/24 at 1:24 PM. The Physician stated monitoring of weights was the facility's responsibility and was important to evaluate the resident's nutritional status. The Physician indicated that weights were to be obtained as ordered and the recommendations made by the Registered Dietitian should be evaluated and addressed.

35173

4. Resident #52 was admitted to the facility on [DATE REDACTED].

A physician's order dated 05/02/24 for Resident #52 revealed to obtain weights on admission then weekly for three weeks, then monthly or as specified by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Review of Resident #52's electronic medical record from admission on 05/02/24 through 06/14/24 revealed

an admission weight recorded on 05/02/24 which was 192.6 pounds. There were no other weights recorded. Level of Harm - Minimal harm or potential for actual harm The Minimum Data Set admission assessment dated [DATE REDACTED] revealed Resident #52 was severely cognitively impaired and required set up or clean up assistance with eating. Resident #52 was on a regular diet and her Residents Affected - Some weight was recorded as 193 pounds. There was no weight loss or gain. The care area assessment indicated to initiate a care plan with interventions for nutritional status.

An interview was conducted with the Registered Dietitian (RD) on 06/12/24 at 2:45 PM. The RD indicated Resident #52's weights were not obtained weekly as ordered. The RD stated weights were necessary to make recommendations, evaluate the resident's nutritional needs and evaluate current interventions. The RD stated it was difficult to determine the cause of Resident # 52's weight changes without obtaining weekly weights as ordered. The RD stated she was aware the weekly weights were not getting done and had reported it to Administration.

An interview was conducted with Nurse #7 on 06/13/24 at 11:45 AM. Nurse #7 reported the nurse aides obtained the monthly weights and the weights were given to the nurse to enter into the electronic medical record. She stated she was not aware Resident #52 had an order for weekly weights because nothing populated in the electronic medical record to notify her that a weekly weight was needed. She stated any newly admitted residents should have weekly weights for one month and then changed to monthly thereafter.

An interview was conducted with Nurse Aide (NA) #8 on 06/14/24 at 1:11 PM. NA #8 reported she was usually given a list at the beginning of the month of residents who needed a monthly weight. NA #8 added, if

a nurse needed a weekly or daily weight she would let her know. NA #8 stated she had not been told to obtain Resident #52's weight and had not received a list of residents who needed monthly weights as of this time. She stated when the weights were obtained she would give them to the assigned Nurse and she believed they would enter them in the electronic medical record.

An interview was conducted with Unit Manager (UM) #2 on 06/14/24 at 2:00 PM. UM #2 stated she was responsible for ensuring the weekly and monthly weights were obtained. She stated with new admissions, part of the admission process was to initiate batch orders for weekly weights. She stated the order for the weekly weights that she entered into the electronic record was not entered correctly to populate to the medication administration record to alert nursing staff that a weight was due. UM #2 added due to this error,

the weekly weight order also did not populate on to her weekly weight report so she was not aware that Resident #52 needed weekly weights for 3 weeks and that was why they were not done.

An interview was conducted with the Director of Nursing (DON) on 06/14/24 at 4:10 PM. The DON stated weights were not obtained timely and accurately. The DON stated she was hired through an agency a few months ago and had not implemented a process for obtaining weights yet but indicated it was an important part of the resident's care and was necessary to evaluate the resident's condition.

An interview was conducted with the Facility Physician on 06/18/24 at 1:24 PM. The Facility Physician stated

she started in the position on 06/07/24 and indicated monitoring of weights was the facility's responsibility and was important to evaluate the resident's nutritional status. The Facility Physician further stated weights were to be obtained as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45711 jeopardy to resident health or safety Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 Residents Affected - Some and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request

on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to

the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to

the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs.

Immediate Jeopardy began when the facility failed to provide effective pain management for Resident #51 on 5/9/24 resulting in a pain level of 10 out of 10, and for Resident #46 on 5/12/24 when the resident had increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective.

Findings included:

Gabapentin is an anticonvulsant medication prescribed for seizures and nerve pain. Manufacturer instructions indicated gabapentin caused physical dependence and stopping the medication results in withdrawal symptoms. Within 12 hours after stopping gabapentin, withdrawal symptoms may start and may be severe. Withdrawal symptoms include nausea, insomnia, anxiety, tremors, body aches, increased pain, hallucinations and seizures.

1. Resident #51 was admitted on [DATE REDACTED] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities).

Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain.

Review of Resident #51's physician orders revealed an order dated 4/10/24 for methadone 5 mg 2 times per day for pain and an order dated 4/18/24 for baclofen 20 mg 3 times per day for muscle spasms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Review of Resident #51's care plan revealed a focus dated 11/7/23 of pain due to chronic back pain. The goal indicated resident's pain will be relieved with use of pain medications. Interventions included provide/ Level of Harm - Immediate administer pain medications as ordered, monitor for complaint of pain and report the need for further jeopardy to resident health or interventions. safety

Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated resident was Residents Affected - Some cognitively intact The MDS assessment was coded as received scheduled and as needed pain medication.

The pain interview was not assessed.

The pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated the 92 gabapentin pills from the 4/25/24 supply for Resident #51 were returned to the pharmacy while Resident #51 was in the hospital from 5/5/24 through 5/8/24.

The hospital discharge summary dated 5/8/24 indicated Resident #51 was hospitalized from 5/5/24 through

the morning of 5/8/24. The hospital discharge summary indicated the order for gabapentin for Resident #51 was unchanged when she returned on 5/8/24.

The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and the documentation of a 9 indicated to see the nursing notes. This MAR did not include routine monitoring of pain using a 0-10 pain scale rating. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/8/24

- The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

5/9/24

- The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 A pain assessment dated [DATE REDACTED] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day Level of Harm - Immediate activities were limited due to pain. jeopardy to resident health or safety A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. Residents Affected - Some

An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse # 8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 reported increased pain when she did not receive her gabapentin. Nurse # 8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as order. Nurse #8 stated she did not report Resident #51's concerns about not receiving the medication gabapentin to administration and did not have an explanation for why she did not report the concerns.

A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the writer (Nurse #8) informed Resident #51 there were no interventions for

this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room .

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/10/24

- The MAR for 9:00 AM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

An interview was conducted via phone with Nurse # 9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51 and the resident reported pain in her legs. Nurse #9 indicated it was normal for Resident #51 to refuse her shower.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 revealed she was assigned to Resident #51 on 5/10/24 from 7:00 PM to 7:00 AM. Nurse #13 indicated the ordered medication Level of Harm - Immediate gabapentin 800 mg was unavailable for the scheduled dose at 9:00 PM. Nurse #13 recalled that Resident jeopardy to resident health or #51 normally did not complain of pain other than discomfort from her suprapubic catheter (a tube inserted safety through the abdomen to drain urine from the bladder).

Residents Affected - Some The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/11/24

- The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up.

- The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note.

An interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated

she did not recall if she made any attempt to obtain the medication for Resident #51 and did not assess Resident #51 for pain. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks and prior to that she worked the 7:00 PM to 7:00 AM shift. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall any further details of the situation. Unit Manager #1 stated she did not recall if she had been involved in obtaining

the medication gabapentin for Resident #51.

A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to the emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal.

An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While

in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE REDACTED] at 6:11 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM. Nurse #2 stated she was assigned to Level of Harm - Immediate Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital during the jeopardy to resident health or night on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. safety Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Nurse #2 stated it looked like Resident #51 was exhibiting withdrawal symptoms. Resident #51 requested to Residents Affected - Some be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility, and she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available.

A progress note written by Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51's gabapentin was not available in the facility and the resident was sent to the emergency room during the night

on 5/12/24 to obtain it.

The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM).

Attempts were made via phone to interview Nurse #14, a nurse that worked through an agency as needed. Messages left on 6/13/24 and 6/14/24 with no return call received.

An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE REDACTED] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day.

A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received Gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. The emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM.

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/13/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 - The MAR for 9:00 AM indicated Nurse # 15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. Level of Harm - Immediate jeopardy to resident health or - The MAR for 12:00 PM indicated Nurse # 15 documented a 9 and the corresponding administration record safety note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

Residents Affected - Some - The MAR for 5:00 PM indicated Nurse # 15 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy

Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24.

A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview.

An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 reported pain due to not receiving gabapentin but stated gabapentin was ordered for pain so running out of the medication would cause increased pain.

An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated

she was familiar with Resident #51. NA #1 stated Resident #51 complained of pain at times, but this was not common for her.

An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident #51 complained of leg pain at times.

A follow up interview was conducted via phone with Nurse #8 on 6/27/24 at 6:15 PM. Nurse #8 stated she was aware of the potential for withdrawal and adverse effects that Resident #51 may sustain because of not receiving the ordered doses of gabapentin. Nurse #8 stated muscle aches and spasms were signs of withdrawal.

An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51 resulting in Level of Harm - Immediate missed doses of the medication ordered for pain. The DON indicated there was confusion regarding the jeopardy to resident health or requirements to order and reorder gabapentin and she did not understand the requirements herself. The safety DON revealed the Consultant Pharmacist had informed her of the problem with gabapentin running out but being new to the DON position, she had not investigated the problem. The DON stated a system was Residents Affected - Some required in the facility to track medication refills, especially medications for pain.

An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected pain medication to be administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identified a medication was not available for administration.

An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications, especially pain medications, so they could be administered as ordered.

2. Resident #46 was admitted on [DATE REDACTED] with diagnosis which included diabetes and neuropathy.

Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain.

A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain.

Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated resident was cognitively intact. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident reported no pain in the previous 5 days.

A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8. Gabapentin 800 mg was administered twice per day from 5/1/24 through 5/9/24.

An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked through an agency and was assigned to work at the facility on 5/6/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident # 46. Nurse #2 recalled the gabapentin was Level of Harm - Immediate delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. jeopardy to resident health or Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the safety pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Residents Affected - Some Resident #46 would do it.

The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication:

5/10/24

- The MAR for 9:00 PM indicated Nurse # 3 documented a 9 and there was no corresponding nursing note.

- The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain. Nurse #3 documented the PRN dose was effective.

5/11/24

- The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered.

- The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note.

- The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 7. Nurse #3 documented the PRN dose was effective.

5/12/24

- The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin.

- The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note.

- The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 9. Nurse #3 documented the PRN dose was effective.

5/13/24

- The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 - The MAR for 9:00 PM indicated Nurse # 17 documented a 9. A pain level of 8 was recorded at 10:50 PM.

The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy. Level of Harm - Immediate jeopardy to resident health or - The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone safety acetaminophen for pain. Nurse #17 documented the PRN dose was effective.

Residents Affected - Some 5/14/24

- The MAR for 9:00 AM indicated Nurse # 7 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note.

- The MAR indicated at 9:25 PM Nurse # 17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen. Nurse #17 documented the PRN dose was effective.

5/15/24

- The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note.

5/16/24

- The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 AM indicated waiting for delivery of gabapentin from pharmacy.

- The MAR for 9:00 PM indicated Nurse # 11 documented a 9. The corresponding nursing note on 5/17/24 at 12:40 AM indicated awaiting medication delivery from pharmacy.

5/17/24

- The MAR for 9:00 AM indicated Nurse #5 documented a 9. An administration note dated 5/17/24 at 10:09 AM indicated awaiting medication delivery of gabapentin from pharmacy.

- The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:04 PM.

An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented 9

on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin and indicated the medication was not administered due to it being unavailable. Nurse #3 stated Resident #46 had pain and was unable to sleep when she did not receive the medication gabapentin. Nurse #3 reported she did not relay Resident #46's reports of increased pain to the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that had worked at the facility for several months. Nurse #6 stated she was assigned to Resident #46 Level of Harm - Immediate on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of jeopardy to resident health or gabapentin. Nurse #6 stated the medication was not available on the medication cart. Nurse #6 indicated safety Resident #46 was upset about not receiving her scheduled gabapentin due to having increased pain. Nurse #6 did not report the resident's concerns about pain and did not have an explanation for why. Residents Affected - Some

An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse # 17 stated she was assigned to Resident #46 from 7:00 PM to 7:00 AM shift on 5/13/24, 5/14/24, and 5/15/24. Nurse # 17 stated she looked for the medication on

the medication cart and when she did not see it, she documented it 9, not available. Nurse #17 indicated medications were frequently missing and ran out from the medication cart. Nurse #17 revealed gabapentin was prescribed for pain and Resident #46 exhibited increased pain, irritability and anxiety from not receiving

the medication. Nurse #17 did not report Resident #46's symptoms to the physician or administration and did not have an explanation for why.

An interview was conducted on 6/13/24 at 3:47 PM with Nurse #16. Nurse #16 was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #16 stated she worked at the facility through an agency for about 6 weeks. Nurse #16 stated 9 on the electronic MAR indicated the medication was not available. Nurse #16 indicated she documented 9 for unavailable on Resident #46's MAR on 5/13/24, 5/14/24 and 5/15/24 at 9:00 PM for the scheduled doses of gabapentin. Nurse #16 stated gabapentin was prescribed for pain and Resident #46 reported increased pain and inability to sleep from not receiving her scheduled pain medication.

An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 stated she signed for the dose on the electronic MAR on 5/15/24 at 9:00 AM in error. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not attempt to obtain it or notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 stated she was aware that gabapentin was prescribed for nerve pain and not receiving the medication would cause the resident to have increased pain. Nurse #7 was unable to explain why she did not report Resident #46's increased pain from not receiving the scheduled doses of gabapentin.

An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident reported increased pain. Unit Manager #2 stated she did nothing about Resident #46's medication not being available and did not have an explanation for why.

An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated there was a problem with running out of medications and administration was aware of the problem with medication not coming in from pharmacy. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM and did not call the pharmacy to obtain it. Nurse #5 stated Resident #46 reported increased pain. Nurse #5 stated she the medication was on order, so she did not attempt to obtain it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not Level of Harm - Immediate available for the prescribed dose for Resident #46 on 5/17/24 and the resident reported pain. Nurse #2 jeopardy to resident health or stated she did not call the pharmacy to obtain the prescribed gabapentin for Resident #46. Nurse #2 stated safety medications were frequently unavailable, and she was informed by other nurses, although she did not recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was Residents Affected - Some nothing that could be done.

Attempted to interview Nurse #11, nurse assigned to Resident #46 on 5/16/24 7:00 PM to 7:00 AM. Messages were left on 6/11/24 and 6/12/24 with no return call received.

An interview was conducted with Resident #46 on 6/13/24 at 9:30 AM. Resident #46 stated the facility frequently had trouble obtaining medications. Resident #46 stated she had gone without medications for days at a time on several occasions. Resident #46 reported staff would state the medication was coming from the pharmacy and then it didn't come in. Resident indicated she was familiar with her medications and gabapentin was prescribed for nerve pain. Resident #46 stated she had increased pain, trouble sleeping, was anxious, irritable, nauseous and unable to get up out of bed or complete her usual routine during the time when she did not receive her gabapentin. Resident #46 stated it was horrible and the staff told her she would just have to wait it out until the medication came in.

An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated

she was familiar with Resident #46. NA #1 stated Resident #46 complained of pain at times, but this was not common for her.

An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident # 46 was pleasant, quiet and did not usually complain of pain. NA #9 stated Resident #46's normal routine was to get up out of bed to the wheelchair and attend activities daily.

An interview was conducted via phone with Nurse #5 on 6/27/24 at 6:44 PM. Nurse #5 stated she was aware that suddenly stopping gabapentin could lead to withdrawal symptoms including insomnia, nausea, tremors and anxiety. Nurse #5 stated the symptoms Resident #46 reported could have been withdrawal symptoms.

Review of a 5/27/24 Medication Record Review by the Consultant Pharmacist indicated a medication error was identified in Resident #46's electronic health record. The note indicated gabapentin was marked out of stock for 13 doses in May 2024. The Pharmacist indicated on the note that she checked the pharmacy records and found the pharmacy sent a 30-day supply of the medicatio [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45711 safety Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Residents Affected - Some Physician interview, the facility failed to ensure scheduled medication was obtained and available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale of 0 to 10 with

the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication.

She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication.

Immediate Jeopardy began on 5/9/24 for Resident #51 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in a reported pain scale of 10 out of 10. Immediate Jeopardy began on 5/12/24 for Resident #46 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Example #3 was cited at scope and severity E.

Findings included:

1. Resident #51 was admitted on [DATE REDACTED] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities).

Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain.

Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 The pharmacy records indicated a supply of 120 gabapentin 800 mg pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated 92 gabapentin pills from the 4/25/24 supply for Resident #51 Level of Harm - Immediate were returned to the pharmacy while Resident #51 was in the hospital from 5/5/24 through 5/8/24. jeopardy to resident health or safety The hospital discharge summary dated 5/8/24 indicated Resident #51 was hospitalized from 5/5/24 through

the morning of 5/8/24. The hospital indicated the order for gabapentin for Resident #51 was unchanged Residents Affected - Some when she was discharged on [DATE REDACTED].

A nursing progress note written by Nurse #8 on 5/8/24 at 4:22 PM revealed Resident #51 returned to the facility from the hospital on 5/8/24 at 2:40 PM.

Resident #51's May 2024 Medication Administration Record (MAR) indicated there was no routine pain monitoring.

The May 2024 MAR indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes.

This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/8/24

- The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

5/9/24

- The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

Following readmission to the facility on [DATE REDACTED], a pain assessment dated [DATE REDACTED] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. Level of Harm - Immediate jeopardy to resident health or An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was safety assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 Residents Affected - Some documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 indicated she did not know the process for obtaining medications from the pharmacy and had been informed by other nurses, although she did not recall which nurses, that if a medication was not available, they just had to wait for it to come in. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse # 8 stated frequently medications were not available. Nurse #8 stated a written or electronic prescription was not required to reorder gabapentin. Nurse # 8 stated Resident #51 was frustrated about not receiving the medication gabapentin as order.

A nursing progress note by Nurse #13 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed Resident #51 there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room .

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/10/24

- The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from pharmacy.

An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse #9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse #9 stated Resident #51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse #9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse #9 indicated Resident #51 refused her shower on 5/9/24 which was not normal for her, reporting she was in too much pain. Nurse #9 stated the facility frequently ran out of medications and did not receive medications on time. Nurse #9 stated she did not attempt to obtain medication for Resident #51 and did not know the process for obtaining gabapentin.

Attempts were made to interview Nurse #13 via phone with messages left on 6/13/24 and 6/14/24 with no return call received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: Level of Harm - Immediate jeopardy to resident health or 5/11/24 safety - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing Residents Affected - Some note.

- The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up.

- The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note.

An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51. She stated

she was unclear the requirements for reordering gabapentin and did not assess Resident #51 for pain.

Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received.

A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal.

An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While

in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE REDACTED] at 6:11 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM and was assigned to Resident #51 on Level of Harm - Immediate 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled jeopardy to resident health or pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain safety during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she Residents Affected - Some notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility. Nurse #2 stated she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available.

A progress note written by Agency Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from

the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51 had not received her medications from the pharmacy. Unit Manager #1 wrote down the medication that was needed from the pharmacy. The resident was sent to the emergency room last night to obtain gabapentin.

The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM).

Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. Nurse #14 worked at the facility through an agency.

A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received Gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM.

An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE REDACTED] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day.

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/13/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 - The MAR for 9:00 AM indicated Nurse #15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. Level of Harm - Immediate jeopardy to resident health or - The MAR for 12:00 PM indicated Nurse #15 documented a 9 and the corresponding administration record safety note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

Residents Affected - Some - The MAR for 5:00 PM indicated Nurse #15 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy

Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24.

A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview.

An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 stated

she was in the role of Unit Manager for 3-4 weeks. Unit Manager #1 stated she thought gabapentin required

a written or electronic prescription to be refilled but it had been a while since she ordered it so she was not sure. Unit Manager #1 stated she knew gabapentin had to be kept in the narcotic locked box and signed for. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall when or how she became aware. Unit Manager #1 indicated she did not recall if she had been involved in obtaining the medication gabapentin for Resident #51.

An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated

she thought a written or electronic prescription was required to obtain a refill of gabapentin, but she was not sure. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 had pain due to not receiving gabapentin. Unit Manager #2 stated she had not contacted the pharmacy to obtain the ordered medication gabapentin for Resident #51.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated there was a system process problem with the facility and the ordering and Level of Harm - Immediate reordering of medications, including gabapentin. The Consultant Pharmacist stated there was confusion in jeopardy to resident health or the facility regarding the requirements for ordering and reordering gabapentin and this placed the residents safety at risk of adverse effects. The Consultant Pharmacist stated she discussed the problems with obtaining medications for administration when the current Director of Nursing (DON) came into the position at the Residents Affected - Some facility (DON started position in the end of March) and made her aware of the concerns. Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. The Consultant Pharmacist indicated the pharmacy considered gabapentin a controlled medication for storage and accounting purposes but did not require a written or electronic prescription for refills.

An interview was conducted by phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Pharmacy Quality Assurance Specialist indicated the pharmacy treated gabapentin as a controlled medication in terms in the storage and accounting for it. She stated a written or electronic prescription was not required to obtain the medication from the pharmacy. The Pharmacy Assurance Specialist stated the process for obtaining a refill of the medication gabapentin was the facility sent the refill sticker via fax or completed a refill request in the computer.

An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51. The DON indicated there was confusion regarding the requirements to order and reorder gabapentin and she did not understand the requirements herself. The DON revealed the Consultant Pharmacist had informed her when

she started at the facility at the end of March of the problem with gabapentin not being available. Being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills.

An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be available and administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identify that a medication was not available for administration.

An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered.

2. Resident #46 was admitted on [DATE REDACTED] with diagnosis which included diabetes and neuropathy.

Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated resident was cognitively intact with no behaviors. Resident #46 received scheduled and as needed pain medication, pain Level of Harm - Immediate interview should be conducted, and resident had no pain in the previous 5 days. jeopardy to resident health or safety A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain. Residents Affected - Some

A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8.

An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM and was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this.

An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident #46. Nurse #2 recalled the gabapentin was delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Resident #46 would do it.

Review of a Controlled Drug Record for Resident #46 revealed the last dose from the supply of gabapentin delivered on 4/8/24 was signed out by Nurse #7 on 5/10/24 at 8:00 AM bringing the count to 0 pills remaining.

Resident #46's May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR further indicated there was no routine monitoring of Resident #46's pain level.

The May 2024 MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication:

5/10/24

- The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note.

- The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain.

5/11/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered.

Level of Harm - Immediate - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A jeopardy to resident health or pain level of 7 was recorded at 9:43 PM. safety - The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone Residents Affected - Some acetaminophen.

5/12/24

- The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin.

- The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A pain level of 9 was recorded at 9:37 PM.

- The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen.

5/13/24

- The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin.

- The MAR for 9:00 PM indicated Nurse #17 documented a 9. A pain level of 8 was recorded at 10:50 PM.

The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy.

- The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for pain.

5/14/24

- The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note.

- The MAR indicated at 9:25 PM Nurse #17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen.

5/15/24

- The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #17 documented a 9 and there was no corresponding nursing note.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 5/16/24

Level of Harm - Immediate - The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 jeopardy to resident health or AM indicated waiting for delivery of gabapentin from pharmacy. safety - The MAR for 9:00 PM indicated Nurse #11 documented a 9. The corresponding nursing note on 5/17/24 at Residents Affected - Some 12:40 AM indicated awaiting medication delivery from pharmacy.

5/17/24

- The MAR for 9:00 AM indicated Nurse #5 documented a 9. An administration note dated 5/17/24 at 10:09 AM indicated awaiting medication delivery of gabapentin from pharmacy.

- The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:04 PM.

An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented 9

on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin and indicated the medication was not administered due to it was unavailable. Nurse #3 stated she was unaware of the process to obtain the medication and she did not follow up to obtain the medication. Nurse #3 stated Resident #46 had pain and was unable to sleep which was a change from the norm when she did not receive the medication gabapentin.

An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that had worked at the facility for several months. Nurse #6 stated she administered the prescribed dose of gabapentin on 5/11/24 at 9:00 AM from the emergency medication delivery system as it was not available on the medication cart. Nurse #6 stated she was told by someone, unable to recall who, after she gave the dose from the emergency medication delivery system that she was not to do so since it was not the correct dose. The emergency medication delivery system contained gabapentin 100 mg tablets and Resident #46's physician order was for 800 mg. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart and she did not obtain it from the emergency medication delivery system on 5/12/24 or 5/13/24. Nurse #6 stated she was not aware of the process for obtaining a medication that was not available.

An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse # 17 stated she was assigned to Resident #46 from 7:00 PM to 7:00 AM shift on 5/13/24, 5/14/24, and 5/15/24. Nurse #17 stated she looked for the medication on the medication cart and when she did not see it, she documented it 9, not available. Nurse #17 indicated medications were frequently missing and ran out from the medication cart. Nurse #17 stated she did not notify the pharmacy or the provider that the medication was not available. Nurse #17 revealed gabapentin was prescribed for pain and Resident #46 exhibited increased pain, irritability and anxiety from not receiving

the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 An interview was conducted on 6/13/24 at 3:47 PM with Nurse #16. Nurse #16 was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #16 stated 9 on the electronic MAR Level of Harm - Immediate indicated the medication was not available. Nurse #16 indicated she documented 9 for unavailable on jeopardy to resident health or Resident #46's MAR on 5/13/24, 5/14/24 and 5/15/24 at 9:00 PM for the scheduled dose of gabapentin. safety Nurse #16 stated gabapentin was not on the medication cart for Resident #46, Nurse #16 stated she worked at the facility through an agency for about 6 weeks. Nurse #16 stated medications were frequently missing Residents Affected - Some from the medication cart. Nurse #16 stated she did not call the pharmacy to obtain the medication. Nurse #16 stated gabapentin was prescribed for pain and not receiving the medication caused Resident #46 increased pain.

An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 stated she signed for the dose on the electronic MAR on 5/15/24 at 9:00 AM in error. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not attempt to obtain it or notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 stated she was aware that gabapentin was prescribed for nerve pain and not receiving the medication would cause the resident to have increased pain and should be monitored for this. Nurse #7 was unaware of the process for obtaining a medication that was not available.

An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she thought a written or electronic prescription was required to obtain a refill of gabapentin. Unit Manager #2 stated there had been delays in receiving refills of gabapentin, but she did not know why and Resident #46 had gone without the medication. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident had increased pain and she did not attempt to obtain it. Unit Manager #2 stated she did nothing about Resident #46's medication not being available.

An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated there was a problem with running out of medications and medications not being available. Nurse #5 stated she used the computer to reorder medications, but they frequently did not come in and she did not know why. Nurse #5 stated administration was aware of the problem with medication not coming in from pharmacy. Nurse #5 stated she did not know if a written or electric prescription was needed to reorder gabapentin. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM, did not call the pharmacy to obtain the medication and observed Resident #46 to have increased pain which was abnormal for the resident. Nurse #5 stated she the medication was on order, so she did not attempt to obtain it.

An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and resident had increased pain. Nurse #2 stated she did not call the pharmacy to obtain the prescribed [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45711 jeopardy to resident health or safety Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant Residents Affected - Some medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24.

Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being

the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility.

Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs.

Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE REDACTED] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection).

In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in

the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Immediate Jeopardy began on: 3/14/24 for Resident #269 when haloperidol and carvedilol were not administered as ordered and the resident required ED evaluation due to shortness of breath and an elevated Level of Harm - Immediate pulse; 5/9/24 for Resident #51 when gabapentin not being administered as ordered resulted in a 10 out of 10 jeopardy to resident health or pain scale; 5/12/14 for Resident #46 when gabapentin not being administered as ordered resulted in safety increased pain and difficulty sleeping, and on 3/15/24 for Resident #419 when the resident's IV dislodged (came out of her vein) and the nurse was unable to restart the IV to administer the ordered antibiotic. Residents Affected - Some Immediate Jeopardy was removed on 6/15/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Examples #5, #6, #7, #8, and #9 were cited at scope and severity E.

Findings included:

1. Review of Resident #269's hospital discharge summary dated 3/7/24 indicated the resident was to receive haloperidol 2 tablets of 2 milligrams (mg) at bedtime for mood and carvedilol 12.5 mg twice per day.

Resident #269 was admitted on [DATE REDACTED] with diagnoses which included congestive heart failure, atrial fibrillation and toxic encephalopathy (a neurological disorder caused by exposure to toxic substances).

Resident #269's admission physician orders entered on 3/7/24 included haloperidol 20 mg at bedtime for mood. The order was entered into the computer by the previous Director of Nursing (DON).

Resident #269's admission physician orders entered on 3/7/24 did not include carvedilol 12.5 mg as indicated in his hospital discharge summary.

Review of Resident #269's medical record revealed the admission assessment was completed by Nurse #9

on 3/7/24 at 3:22 PM.

Review of Resident #269's March 2024 Medication Administration Record (MAR) revealed haloperidol 20 mg was scheduled to be administered at 8:00 PM. The MAR was blank on 3/7/24 for the scheduled 8:00 PM dose. The MAR revealed the medication was electronically signed as administered on 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/13/24. The MAR further revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily from admission on 3/7/24 through the morning of 3/14/24 as indicated in the hospital discharge summary. This resulted in 14 missed doses of the medication from admission on 3/7/24 through the morning of 3/14/24.

Resident #269's admission Minimum Data Set (MDS) dated [DATE REDACTED] indicated resident was cognitively intact and received antipsychotic medication.

Review of Resident #269's March 2024 MAR revealed vital signs were to be obtained every shift. On 3/14/24 day shift (7:00 AM to 3:00 PM) the following were recorded: Blood pressure 162/90 (elevated), pulse 113 (elevated), respirations 20 and temperature 97.0 degrees Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of Resident #269's electronic health record revealed a nursing progress note written by Nurse #9 dated 3/14/24 at 12:10 PM which indicated resident complained of shortness of breath and stated he did not Level of Harm - Immediate feel right. Resident #269's vital signs were: blood pressure 136/90, pulse 113 (elevated), respirations 22, jeopardy to resident health or temperature 97.5 and oxygen saturation of 98% on 3 liters of oxygen. Resident #269 requested to go to the safety hospital. On 3/14/24 at 12:25 PM Resident #269 went out of the facility to the emergency department.

Residents Affected - Some An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:00 PM. Nurse # 9 stated she was no longer employed at the facility. Nurse #9 stated she was assigned to Resident #269 on 3/14/24 when he requested to be sent to the emergency room for evaluation. Nurse #9 stated Resident #269 was not doing well that day. Nurse #9 further stated Resident #269 complained of not feeling well, stating he knew something was wrong, his pulse was elevated, he was short of breath and reported he did not feel good all over. Nurse #9 stated after she sent Resident #269 to the hospital, she reviewed his medications and saw

the dose of haloperidol was 20 mg. Nurse #9 stated she did not administer Resident #269 haloperidol on her shift as it was ordered to be given on night shift. Nurse #9 indicated if she saw a dose of 20 mg of haloperidol

on the MAR to be given, she would not have given it since it was a higher dose than normally ordered. Nurse #9 stated she would clarify a dose that was higher than normal with the doctor.

An Emergency Department (ED) Provider Report dated 3/14/24 at 4:24 PM indicated Resident #269 was evaluated with a chief complaint of shortness of breath. Chest x ray and laboratory tests were obtained with no further treatment required. Vital signs upon discharge from the emergency department were blood pressure 138/88, respirations 18 and oxygen saturation 94 percent. The discharge medication list indicated Resident #269 was to receive in part the medication haloperidol 2 tablets of 2 mg at bedtime and carvedilol 12.5 mg twice per day. There was no indication in the ED report of the significant medication errors with haloperidol or carvedilol.

Review of the electronic health record for Resident #269 revealed the resident returned to the facility on [DATE REDACTED] at 6:44 PM.

Review of Resident #269's physician orders revealed an order dated 3/14/24 for haloperidol 2 mg give 1 tablet at bedtime for mood. The order was entered by the previous DON and was discontinued on 3/15/24.

Review of the March 2024 MAR for Resident #269 revealed haloperidol 2 mg give 1 tablet at bedtime on 3/14/24 at 8:00 PM was documented with a 9 indicating to see nurses notes. Review of Resident #269's nursing progress notes revealed there was no corresponding note on 3/14/24 at 8:00 PM.

Review of Resident #269's physician orders revealed an order dated 3/15/24 for haloperidol 2 mg give 2 tablets at bedtime for mood.

Review of Resident #269's electronic health record revealed an incident note written by Nurse #4 on 3/15/2024 at 3:58 PM. The note indicated Resident #269's order for haloperidol was transcribed in the computer incorrectly. The progress note indicated Resident #269 received the incorrect dose of haloperidol

on 3/8, 3/9, 3/10, 3/11, 3/12, and 3/13/24.

Attempts were made to interview Nurse #4 via phone with messages left on 6/11/24 and 6/12/24 with no return call received. Nurse #4 no longer worked at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The order for carvedilol 12.5 mg indicated in the 3/14/24 ED discharge summary was not entered into Resident #269's physician orders when the resident returned to the facility. Level of Harm - Immediate jeopardy to resident health or The March 2024 MAR revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily on the safety evening of 3/14/24 through the morning of 3/20/24 as indicated in the ED discharge summary. This resulted

in 12 missed doses of the medication. Residents Affected - Some

A nursing progress note dated 3/20/24 at 11:50 AM written by Nurse #7 stated resident was discharged home.

An interview was conducted with Nurse #13 via phone on 6/27/24 at 12:50 PM. Nurse #13 was assigned to Resident #269 on 3/8/24 from 7:00 PM to 7:00 AM and administered the haloperidol 20 mg on 3/8/24 at 9:00 PM. Nurse #13 stated she administered the medication as ordered and documented on the MAR. Nurse #13 did not recall any further information regarding the dose of haloperidol.

An interview was conducted via phone with Nurse #8 on 6/13/24 at 5:12 PM. Nurse #8 confirmed she was assigned to Resident #269 from 7:00 PM to 7:00 AM on 3/9/24 and she administered haloperidol 20 mg according to the physician order and as documented on the MAR. Nurse #8 stated she did not think about it at the time to clarify or hold the haloperidol due to an excessive dose.

An interview was conducted with Unit Manager #1 on 6/13/24 at 9:30 AM. Unit Manager #1 stated she was assigned to Resident #269 on 3/11/24, 3/12/24 and 3/13/24. Unit Manager stated she administered the ordered doses of haloperidol to Resident #269 at 9:00 PM on 3/11/24, 3/12/24 and 3/13/24. Unit Manager #1 stated she did not question the dose or obtain a clarification of the dose prior to administering it.

An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated normally, the floor nurses entered the orders in the computer without verifying the orders with the Physician when a resident was admitted . Unit Manager #2 stated she was not sure who was supposed to fax the orders from the hospital, that she did not do it and she thought it must be someone from administration. Unit Manager #2 confirmed she was assigned to Resident #269 on 3/10/24 and her electronic signature on the MAR indicated she administered the 9:00 PM dose of haloperidol 20 mg. Unit Manager #2 stated it did not occur to her to clarify the dose or hold the haloperidol due to the dose of 20 mg ordered being higher than a usual dose ordered.

An interview was conducted via phone with the previous Director of Nursing (DON) on 6/13/24 at 1:20 PM.

The previous DON stated she entered the orders into the computer for Resident #269 on 3/7/24 when he was admitted to the facility from the hospital. She stated she entered the order for haloperidol incorrectly.

She indicated she did not know why she put the order in incorrectly and couldn't say what happened. The previous DON revealed she was not aware she omitted the order for carvedilol and she did not have an explanation for why other than human error. The previous DON indicated she did not recall if she sent the discharge summary to the pharmacy. The previous DON stated she recalled Resident #269 went to the emergency room but did not know why or the outcome. The previous DON stated she left the position at the facility shortly after the resident was sent to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 An interview was conducted via phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Quality Assurance Specialist indicated the pharmacy dispensed 30 tablets of haloperidol 20 mg on Level of Harm - Immediate 3/7/24 for Resident #269. The Quality Assurance Specialist indicated the pharmacy did not receive the jeopardy to resident health or hospital discharge summary dated 3/7/24 for Resident #269. The Quality Assurance Specialist stated safety normally the pharmacist compared the discharge summary and the orders that were entered and would call

the facility for clarification or to report discrepancies. The Quality Assurance Specialist indicated Residents Affected - Some documentation in the pharmacy record indicated the pharmacy did not receive a discharge summary for Resident #269. The pharmacy record indicated the pharmacist called the facility on 3/7/24 and was informed by the previous Director of Nursing (DON) to send all Resident # 269's medications as they were entered into the computer. Precautions indicated to use haloperidol with extreme caution with residents with cardiac arrhythmia. The Quality Assurance Specialist stated there was no dosage warning in the computer for the haloperidol dosage.

An interview was conducted via phone with the Consultant Pharmacist on 6/12/24 at 9:15 AM. The Consultant Pharmacist indicated haloperidol 20 mg was a high dose which was usually only prescribed in an acute setting with a major psychiatric diagnosis. The Consultant Pharmacist indicated the high dose of haloperidol had the potential for adverse effects including harm and receiving the medication at that dose for

a sustained period increased the likelihood of effects. The Consultant Pharmacist stated adverse effects could include but were not limited to sedation, somnolence, movement disorders, drooling and severe respiratory difficulty. The Consultant Pharmacist stated the haloperidol error was a significant medication error. The Consultant Pharmacist reported the omission of carvedilol could result in harm due to potential for exacerbation of atrial fibrillation (irregular heart rate) and congestive heart failure. The Consultant Pharmacist indicated there was a systemic problem with medication administration in the facility for some time and she addressed this with the current DON when she started in March. The Consultant Pharmacist indicated the pharmacy was supposed to receive a copy of the discharge orders to reconcile that with what was entered into the computer by the facility.

An interview was conducted via phone with the Physician on 6/11/24 at 1:00 PM. The Physician stated she was new to the facility having started on 6/7/24. The Physician stated in her career as a physician she had never prescribed a dose of 20 milligrams of haloperidol. The Physician indicated the recommended dose that

she would prescribe was 2.5 milligrams to 5 milligrams as a one-time dose for an acute psychotic episode.

The Physician further stated 6 doses of 20 mg of haloperidol had the potential for serious adverse effects such as sedation, increased tiredness, and respiratory difficulty. The Physician reported the omission of carvedilol from Resident #269's medication list from admission on 3/7/24 through discharge on 3/20/24 was concerning and had the potential for serious adverse effects including changes in blood pressure, heart rate, shortness of breath and worsening of congestive heart failure.

An interview was conducted with the current Director of Nursing (DON) on 6/12/24 at 2:15 PM. The DON indicated the incorrect dose of haloperidol administered to Resident #269 was a significant medication error.

The DON stated she was aware of the error with the transcription of Resident #269's orders and stated the error was made by the previous DON. The DON stated she did not recall how she was made aware of the error. The DON stated she expected orders to be transcribed correctly and the discharge summary to be faxed to the pharmacy by the floor nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 An interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated it was her expectation that medications would be transcribed and administered correctly. She stated she was Level of Harm - Immediate unaware of the error that occurred with the transcription of Resident #269's medications. jeopardy to resident health or safety 2. Resident #51 was admitted on [DATE REDACTED] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes Residents Affected - Some progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities).

Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain.

Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed.

The May 2024 Medication Administration Record (MAR) indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/8/24

- The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

5/9/24

- The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note.

Following readmission to the facility on [DATE REDACTED], a pain assessment dated [DATE REDACTED] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. Level of Harm - Immediate jeopardy to resident health or An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was safety assigned to Resident #51 on 5/8/24 and 5/10/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 Residents Affected - Some documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse #8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as ordered.

A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room .

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/10/24

- The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51.

An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 stated Resident #51's gabapentin was unavailable, and she had not administered it. Nurse #13 stated she did not attempt to obtain the medication for Resident #51.

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/11/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. Level of Harm - Immediate jeopardy to resident health or - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding safety nursing note.

Residents Affected - Some - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up.

- The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note.

An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51.

Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received.

A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal from not receiving her medication as ordered.

An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While

in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE REDACTED] at 6:11 AM.

An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM. Nurse #2 was assigned to Resident #51

on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital.

A progress note written by Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51 had not received her gabapentin and was sent to the emergency room last night to obtain it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 Level of Harm - Immediate returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next jeopardy to resident health or scheduled dose of gabapentin was due at 9:00 AM). safety Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no Residents Affected - Some return call received.

A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM.

An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE REDACTED] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day.

The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin:

5/13/24

- The MAR for 9:00 AM indicated Nurse #15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

- The MAR for 12:00 PM indicated Nurse #15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy.

- The MAR for 5:00 PM indicated Nurse # 15 documented a 9 and there was no corresponding nursing note.

- The MAR for 9:00 PM indicated Nurse # 11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy

Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on 5/13/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. Level of Harm - Immediate jeopardy to resident health or An interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 stated she was in safety the role of Unit Manager for 3-4 weeks. Unit Manager #1 recalled Resident #51 ran out of gabapentin and required emergency room evaluations due to not receiving the medication. Unit Manager #1 did not recall Residents Affected - Some when or how she became aware of the medication errors of Resident #51 not receiving the ordered medication gabapentin.

An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist stated she discussed the problems with obtaining medications for administration in March when the current Director of Nursing (DON) came into the position at the facility. The Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate) and was a significant medication error. The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe.

An interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated Resident #51 not receiving the prescribed medication gabapentin from 5/8/24 through 5/13/24 was a significant medication error. The DON revealed the Consultant Pharmacist had informed her of the problem with gabapentin not being available but being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills to prevent further significant medication errors due to not obtaining refills.

An interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identified that a medication was not available for administration.

An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician indicated omission of an ordered medication was a medication error and had the potential for serious adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered.

3. Resident #46 was admitted on [DATE REDACTED] with diagnosis which included diabetes and neuropathy.

Review of Resident #46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated resident was cognitively intact with no behaviors. Resident #46 received scheduled and as needed pain medication, pain Level of Harm - Immediate interview should be conducted, and resident had no pain in the previous 5 days. jeopardy to resident health or safety Review of a Controlled Drug Record for Resident #46 revealed the last dose from the supply of gabapentin delivered on 4/8/24 was signed out by Nurse #7 on 5/10/24 at 8:00 AM bringing the count to 0 pills Residents Affected - Some remaining.

The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication:

5/10/24

- The MAR for 9:00 PM indicated Nurse # 3 documented a 9 and there was no corresponding nursing note.

5/11/24

- The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered.

- The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note.

5/12/24

- The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:0 [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 45711 Residents Affected - Some Based on observation and staff interviews, the facility failed to: discard 10 doses of COVID-19 vaccine and a bottle of senna syrup (a liquid laxative medication) that were expired in the South station medication room for 1 of 2 medication rooms reviewed. The facility failed to store an unopened bottle of eye drops in the refrigerator per manufacturer's instructions on the 400-hall medication cart. The facility failed to dispose of 4 bottles of expired eye drops and had an in use inhaler with no resident name, opened date or expiration date

on the 200 Hall medication cart. The facility failed to label a tube of eye ointment with an opened and expiration date and failed to discard an expired bottle of atropine solution on the 300 Hall medication cart.

This was for 3 of 3 medication carts observed for medication storage.

Findings included:

1a. Observation of the South station medication room was conducted on 6/11/24 at 2:30 PM with Unit Manager #1 in attendance. The following expired medications were observed:

14 doses of COVID-19 vaccine were observed with a printed expiration date of 6/2/24 on the box.

8-ounce bottle of Senna syrup with a printed expiration date of 4/24/24 on the label.

An interview was conducted with Unit Manager #1 on 6/11/24 at 2:30 PM revealed the nurses on the medication carts were to check for expired medications on the carts. Unit Manager #1 stated the pharmacist checked one of the medication carts each time on her monthly visit.

1b. Observation of the 400-hall medication cart on 6/11/24 at 3:00 PM with Unit Manager #1 in attendance revealed:

Resident #421's unopened bottle of latanoprost .005% eye drops with a label which indicated refrigerate until opened. The unopened bottle was noted in the top drawer of the medication cart not refrigerated.

An interview was conducted on 6/11/24 at 3:30 PM with Nurse #7. Nurse #7 indicated the Unit Managers asked the nurses to check the medication carts for expired medications and eye drops that required refrigeration, but she did not know who was responsible for making sure it was done.

1c. Observation of the 200-hall medication cart on 6/11/24 at 3:30 PM with Medication Aide (MA) #3 in attendance revealed:

Resident #14's opened bottle of Vyzulta 0.024% ophthalmic solution with a date opened of 4/22/24. According to the manufacturer's expiration information, it was good for 8 weeks after opening, or 6/10/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Resident #24's dorzolamide/timolol ophthalmic solution 2-0.5% with a date opened of 4/24/24. The manufacturer instructions indicated to discard 4 weeks after opening. or 28 days, which was 5/22/24. Level of Harm - Minimal harm or potential for actual harm Resident #24's latanoprost 0.005% ophthalmic solution with a handwritten date opened of 5/3/24 and an expiration date of 5/31/24. The manufacturer's instructions indicated to discard 4 weeks, or 28 days after Residents Affected - Some opening.

Resident #30's latanoprost 0.005% ophthalmic solution with a handwritten date opened of 5/2/24 and an expiration date of 6/2/24. The manufacturer's instructions indicated to discard 4 weeks or 28 days after opening.

An in-use Ventolin inhaler was found on the medication cart with no resident name or dose. There was no label with a date opened or an expiration date.

1d. Observation of the 300-hall medication cart on 6/11/24 at 3:45 PM with MA#3 in attendance revealed:

Resident #169's ciloxan ophthalmic ointment 0.3% with no date opened and no expiration date on the label.

Resident #20's atropine solution 1% use 1 drop under the tongue every 3 hours as needed. The bottle had a handwritten date opened of 5/9/24 and an expiration date of 6/9/24.

An interview was conducted on 6/11/24 at 3:47 PM with MA # 3. MA # 3 indicated she was new to working

on the medication cart, so she was not sure, but she thought the Unit Managers checked the medication carts.

An interview was conducted with the Director of Nursing (DON) on 6/11/24 at 4:05 PM. The DON stated her expectation was that there would be no expired medications on the medication carts or in the medication rooms. The DON further stated there was a breakdown in the process for checking the medication carts for expired medications and checking that medications were labeled and dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 37673 potential for actual harm Based on record review, observation, and staff interviews, the facility failed to implement their policy for Residents Affected - Many enhanced barrier precautions and hand hygiene during wound care for 1 of 3 residents (Resident #66) whose wound care was observed. The facility also failed to implement an infection surveillance plan for monitoring and tracking infections in the facility to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 70 of 70 residents in

the facility.

Findings included:

1. Review of the facility Enhanced Barrier Precautions policy documented enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include wound care (any skin opening requiring a dressing). EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE (Personal Protective Equipment) required. PPE is available outside the room.

Review of the facility Handwashing/Hand Hygiene policy documented the facility considered hand hygiene

the primary means to prevent the spread of healthcare associated infections. Hand hygiene is indicated: immediately before touching a resident, before performing an aseptic task such as placing an indwelling device or handling an invasive medical device, after contact with blood, body fluids or contaminated surfaces, after touching a resident, after touching the resident ' s environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene.

On 06/14/24 at 10:00 am an observation of the Enhanced Barrier Precautions sign posted on Resident #66's door instructed staff to clean hands before entering and after leaving the room and to wear gloves and a gown for high contact resident care activities including wound care or any skin opening requiring a dressing.

A supply of gowns and gloves were located in a bin in the hallway next to the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An observation of wound care was made on 06/14/24 at 10:12 AM. Present were the Treatment Nurse and

the Wound Care Specialist physician. The physician and the nurse donned gloves and gowns prior to Level of Harm - Minimal harm or entering the room. The physician partially removed the dressing and measured the Stage 4 coccyx pressure potential for actual harm ulcer. Both the physician and the nurse removed their gloves and gowns and discarded them in an acceptable receptacle. In the hallway the physician and the nurse used alcohol based hand rub (ABHR). The Residents Affected - Many physician directed the nurse to change the treatment to a new debriding ointment and a border dressing daily. The Treatment Nurse obtained the new ointment from the treatment cart and entered the room without donning a gown. She donned gloves and removed the old dressing and discarded it in an appropriate receptacle. The nurse discarded her gloves and donned new gloves before applying the new treatment. She did not wash her hands or use ABHR after she discarded her gloves or before moving to a clean body site on

the same resident.

In an interview with the Treatment Nurse after the dressing change on 06/14/24 at 10:30 am she stated she changed her gloves between removing the old dressing and applying the new dressing and she thought that was adequate. She stated she did not think she had to wash her hands if she changed her gloves. She acknowledged she had forgotten to wear a gown prior to reentering the room to complete the dressing change and stated she should have put one on.

In an interview with the Infection Preventionist on 06/14/24 at 1:30 PM she stated the Treatment Nurse should have worn a gown during wound care and performed hand hygiene between removing the old dressing and applying the new dressing.

In an interview with the Agency Director of Nursing on 6/14/24 at 4:30 PM she stated she expected staff to wear the appropriate PPE when treating residents on enhanced barrier precautions and perform hand hygiene when indicated.

49502

2. The facility's Infection Prevention and Control Program policy dated 4/1/24 stated the Infection Preventionist (IP) was responsible for completing surveillance of healthcare associated infections, tracking outbreaks and monitoring standard and transmission precautions.

During a meeting with the Infection Preventionist (IP) on 6/14/24 at 3:49 pm she stated she started this position on 5/06/24 and was still in orientation. She was unable to provide any documentation of tracking or surveillance of infections, infection risks for the facility from May 2023 through May 2024. The IP provided a binder with monthly computer printouts of infections in the facility from January 2024 through June 18, 2024.

During an interview with the Director of Nursing (DON) on 6/12/24 at 11:00 am she stated she began her position as DON on 3/25/24 and was not responsible for infection control.

An interview with the Administrator on 6/14/24 at 4:00 pm revealed she had been the Administrator since 2/02/24 and was Statewide Program for Infection and Epidemiology (SPICE) certified. The Administrator stated the IP had not been monitoring or tracking the infections within the facility. She indicated she was helping the IP who was trying to get infection control in order. The Administrator further stated the facility should have been monitoring and tracking infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or 41387 potential for actual harm Based on record review and staff interviews, the facility failed to ensure all staff received training on Residents Affected - Many dementia care, infection control policies and procedures and the elements of the Quality Assurance Performance Improvement (QAPI) program. This practice had the potential to affect all residents.

Findings included:

A review of the 2023 and 2024 annual education records from April 2023 to May 2024 provided by the facility revealed no documented evidence that dementia care, infection control training on policies and procedures and QAPI training were conducted for the staff.

a. Medication Aide #5's personnel file was reviewed and revealed a date of hire of 11/8/2019. There was no documentation of dementia care, infection control and QAPI training in the personnel file.

A phone interview was conducted on 7/1/2024 at 1:23 pm with Medication Aide #5. During the interview, Medication Aide #5 stated she was not able to recall having QAPI training since April 2023 and thought she had received some training on infection control and dementia care in the last year but was unable to recall for certain.

b. Nurse Aide (NA) #2's personnel file was reviewed and revealed a date of hire of 8/13/2018. There was documentation NA# 2 had received dementia care training on 12/5/2023, and there was no documentation NA #2 had received infection control training on policies and procedures and QAPI training.

A phone interview was conducted on 6/18/2024 at 5:49 pm with NA #2. She stated she felt like training as a whole had been overlooked with the all changes in the administrative team. She indicated she had received training on dementia care and QAPI training since changing roles as the activities director in 2024. She only recalled attending an in-service about not wearing gloves into the hallway as infection control training since April 2023.

c. On 6/18/2024 at 06:14 pm in a phone interview with Nurse #8 who had worked at the facility the last two years, she stated she did not know what QAPI was. She said she had not received training while at the facility on QAPI or dementia care and had not received infection control training on policies and procedures since April 2023.

d. On 6/19/2024 at 8:31 am in a phone interview with Medication Aide #3, she stated she had worked at the facility since 8/2023. When asked if she had received QAPI training,, Medication Aide #3 stated she did not know what QAPI was. Mediation Aide #3 further stated she had not received infection control training and did not recall receiving dementia care training since 8/2023.

e. On 6/1/2024 at 7:56 am in a phone interview with Minimum Data Set (MDS) Nurse #4, she stated There had been no infection control and QAPI training since April 2023 and she was unable to recall receiving dementia care training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 84 345185 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345185 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Living and Rehab Center 106 Cameron Street Lake Waccamaw, NC 28450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 On 6/14/2024 at 4:11 pm in a phone interview with the Admissions Coordinator, she stated the facility did not have any evidence that infection control training and QAPI training was provided to all the staff at the facility. Level of Harm - Minimal harm or She explained when the previous Staff Development Coordinator (SDC) resigned, the SDC's office was potential for actual harm cleaned and no one knew what happened to all the training documentation of all the staff at the facility.

Residents Affected - Many In a phone interview with the Director of Nursing (DON) on 6/19/24 at 10:22 am, she stated there was no Staff Development Coordinator (SDC) at the facility when she was hired in March 2024. The DON also stated she was unable to locate any files documenting dementia care, infection control training on policies and procedures and QAPI training to the staff since April 2023. She stated since there was no SDC, she was responsible for documenting the staff's training conducted by different administrative staff members, and stated since March 2024 she had not recorded any training hours and could not recall having training on dementia care, infection control and QAPI training.

A phone interview was conducted on 6/19/24 at 12:25 P.M. with the Administrator. The Administrator explained when the SDC resigned two months ago, the SDC role was originally assigned to the new MDS Nurse #2 who was hired in April 2024. She explained MDS Nurse #2 was unable to manage the educational training due to learning the role as an MDS nurse and working on the back log of MDS assessments in the facility. She revealed MDS Nurse #2 had resigned during the state survey. She stated the facility currently did not have a Staff Development Coordinator and the responsibilities of the SDC for ensuring staff received

the required annual training of dementia care, QAPI and infection control and documentation of the training fell ultimately to the DON to ensure completion. The Administrator explained there had been a high turnover

in the DON position and felt the responsibility of scheduling dementia care, infection control and QAPI training for all the staff and tracking training had been overlooked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 84 345185