Resorts At Beaufort
Resorts at Beaufort in Beaufort, SC — inspection on January 8, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 01/07/25 at 4:44 PM, with the Unit Manager (UM), revealed R33's catheter bag
catheter bag wasn't present and she is aware that the catheter bag should not be on the floor because that could cause infection, and the covering is a dignity issue for the patient.
The UM stated that she will take care of this matter now.
During an interview on 01/08/25 at 9:21 AM, the Director of Nursing (DON), stated that staff uses stat locks in place on residents to keep catheter tubing from kinking. DON stated that her staff visually observes the foley catheters to see whether it is kinking as well.
She stated that the foley catheter bag should never be on the floor and should have a privacy bag covering to protect the patient and prevent infection.
The DON states she has never witnessed the foley bag being on the floor in R33's room.
425067 01/08/2025
Resorts at Beaufort 11 Todd Drive Beaufort, SC 29901
During an interview on 01/08/25 at 10:25AM, the Administrator stated the policy on MDS is to ensure
they are completed timely. It depends on the issue that is being addressed when the MDS needs to be updated.
She ensures her staff are following the regulation by viewing monthly validation reports.
During an interview on 01/08/25 at 10:18 AM with the Director of Nursing (DON), the DON states that she couldn't verbalize the MDS policy, unless she is looking at it.
She states, the MDS is used to update the patients' health condition.
During an interview on 01/08/25 at 10:28 AM with the Risk Manager (RM) revealed the RM states the minimum data assessment tool is used to evaluate a resident's condition and provide guidelines.
She states the MDS needs to be updated quarterly and with any change in the residents' condition, whether it's an improvement or a decline in resident's condition.
425067 01/08/2025
Resorts at Beaufort 11 Todd Drive Beaufort, SC 29901
rate of 5 % (percent) or greater.
The error rate was 7.14 % based on 1 of 5 residents observed during
on [DATE] with diagnoses including, but not limited to vitamin deficiency and essential (primary) hypertension.
Findings
The facility policy entitled Medication Administration - General Policies and Procedures revised 11/1/2015 states Medications are administered as prescribed in accordance with good nursing principle and practices Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
On 01/07/25 at approximately 09:58 AM, LPN (Licensed practical Nurse)1 administered the following medications to R46: -Vitamin D3 125 mg (milligram) (5,000 IU (International Units) ) x 1 -Metoprolol Tartrate 25 mg x 1 On 1/7/25 at approximately 11:10 AM, during medication reconciliation, a review of the January 2025 physician's orders for R46, provided by the (DON) Director of Nursing, revealed: -an order dated 8/12/2024 for Vitamin D2 Oral Tablet (Ergocalciferol) Give 1250 mcg (microgram) orally one time a day every Tue (Tuesday) related to VITAMIN DEFICIENCY. -an order dated 6/10/2024 for Metoprolol Tartrate Oral Tablet 25 mg (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN (hypertension) Hold if SBP (systolic blood pressure) less than 100 or dbp (diastolic blood pressure) less than 80.
On 1/7/25 at approximately 11:15 AM, a review of the January 2025 medication administration record provided by the DON revealed that Metoprolol Tartrate Oral Tablet 25 mg had been also been administered when the dbp was less than 80 on 1/1/2025 and 1/2/2025.
On 01/07/25 at approximately 11:26 AM, during an interview, LPN1, after reviewing the physician's orders, acknowledged the two errors and stated I'm not used to having orders read less than 80 dystolic.
425067 01/08/2025
Resorts at Beaufort 11 Todd Drive Beaufort, SC 29901
Based on observations, record reviews, interviews and manufacturer package inserts, the facility
operative.
Findings include: Review of the facility policy entitled Storage of Medications revised 11/1/2015 states Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Manufacturer package inserts for insulin recommend storage for not in-use (unopened) insulin be stored in a refrigerator at approximately 36-46 degrees F.
On 1/07/25 at approximately 10:49 AM, inspection of the Hall A Medication Room revealed the refrigerator thermometer reading was 48 degrees F (Fahrenheit) and plastic bags of insulin for approximately three residents were lying on shelves in standing water with thawed ice packs in the freezer compartment.
The temperature log affixed to the refrigerator door had a recorded temperature on 1/6/25 of 38 degrees with numerous prior entries reading 38 degrees.
On 1/07/25 at approximately 10:54 AM, Registered Nurse (RN)1 confirmed the refrigerator thermometer reading was 48 degrees F, started cleaning water from the refrigerator and stated the 3rd shift was responsible for checking and recording refrigerator temperatures.
On 1/07/25 at approximately 11:30 AM, the Administrator stated maintenance had found that the refrigerator wasn't working and was being replaced.
425067 01/08/2025
Resorts at Beaufort 11 Todd Drive Beaufort, SC 29901
visually observes the foley catheters to see whether it is kinking as well.
She stated that the foley
floor in R33's room.
Review of R33's face sheet revealed she was admitted to the facility on [DATE] with diagnosis including, but not limited to, Cerebral Palsy, neuromuscular dysfunction of bladder, retention of urine, and lack of coordination.
Review of R33's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/04/24 revealed R33 had a Brief Interview of Mental Status (BIMS) score of 10 of 15, indicating that the resident has a moderate cognitive impairment. Resident 33 is always incontinent of bowel and bladder and has an indwelling catheter.
Review of R33's Care Plan with a start date of 08/21/24, revealed R33 prefers some activities out of room as well as all things Catholic. It also includes, R33 has a suprapubic catheter related to urinary retention and neurogenic bladder.
Interventions include: The resident has a (16Fr) indwelling catheter, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks during rounds each shift initiated on 08/12/24.
Review of R33's Progress Note dated 11/05/24 revealed, Resident is s/p antibiotic therapy, completed Keflex r/t urinary tract infection (UTI) on 11/02/24. No adverse reactions noted at this time. RR e/u w/o any distress noted. No concerns or complaints at this time.
Resident resting in bed with call light in reach.
Plan of care ongoing.
During an observation on 01/06/25 at 12:00 PM, R33 was in bed watching television.
Her foley bag was full of urine and lying on the floor.
There was no privacy cover over the foley catheter bag.
During an observation on 01/07/25 at 4:30 PM, R33 was sitting in her wheelchair in her room watching television.
Her foley catheter bag was on the floor behind her wheelchair with no privacy covering.
During an interview on 01/07/25 at 4:44 PM, with the Unit Manager (UM), revealed R33's catheter bag was on the floor behind her wheelchair and did not have a privacy covering. UM stated the privacy catheter bag wasn't present and she is aware that the catheter bag should not be on the floor because that could cause infection, and the covering is a dignity issue for the patient.
The UM stated that she will take care of this matter now.
425067
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 425067 B.
Wing 01/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Resorts at Beaufort 11 Todd Drive Beaufort, SC 29901
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.