Lake Emory Post Acute Care

F-F600, constituting substandard quality of care.

Findings include:

Review of the facility's undated policy titled Abuse, Neglect, Exploitation, or Mistreatment documented, The facility's Leadership prohibits neglect, mental, physical and or verbal abuse . Component IV: Identification . 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness.

Review of Resident R2's Face Sheet revealed Resident R2 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder.

Review of Resident R2's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/24, revealed Resident R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating Resident R2 was severely cognitively impaired. Under the section behaviors, it recorded Resident R2 as wandering daily.

Review of Resident R2's Elopement assessment dated [DATE REDACTED], indicated Resident R2 was not oriented to her surroundings, and she is confused. Additionally, Resident R2 has a history of wandering and requires supervision, intervention, and wander guard.

Review of Resident R2's Physician Orders revealed an order dated 11/22/22, which revealed to have a wander guard

on at all times, check function and placement every shift.

Review of Resident R2's Care Plan dated 06/18/24, revealed Resident R2 was an elopement risk, requiring wander guard on wrist and will wander safely within the facility with no elopement attempts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 Review of Resident R3's Face Sheet revealed Resident R3 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to, vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic Level of Harm - Immediate heart disease. jeopardy to resident health or safety Review of Resident R3's Admission MDS with an ARD of 09/20/22, revealed Resident R3 had a BIMS score of 6 out of 15, indicating Resident R3 was severely cognitively impaired. Residents Affected - Few

Review of Resident R3's Elopement assessment dated [DATE REDACTED], revealed a diagnosis of vascular dementia, not oriented to place or time, has a history of wandering and states Resident R3 does not have a diagnosis that requires supervision. The intervention listed was a wander guard.

Review of Resident R3's Physician Orders dated 09/14/22, revealed an order to monitor for function and placement of wander guard every shift.

Review of Spartanburg Weather for the date of 08/11/24, recorded a high temperature of 87 degrees Fahrenheit and a low temperature of 71 degrees Fahrenheit with no precipitation.

Review of a statement provided by Registered Nurse (RN) on 08/11/24 at approximately 9:00 PM, revealed Resident R2 and Resident R3 were let out the back door by the RN, on duty along, with other smokers with no escort or supervision. The RN's written statement reported, . [Resident R2 and Resident R3] verbalized attention to smoke and were last visualized at 2100 . Residents returned at approximately 2145.

During an interview on 08/13/24 at 10:45 AM, the Assistant Director of Nursing (ADON) stated, I got a call from a nurse at the facility around 9:03 PM on 08/11/24, to report two residents were missing from Unit 2 and

she couldn't find the nurse. She couldn't give me much information, so I got in my car and headed to the building. The [RN] called me to tell me they were missing as I was on the phone with 3 CNA's [Certified Nursing Assistants] on speaker, who were out looking for them. I heard the CNA say, Lets follow EMS as

they passed the facility. They did and said they had found the two residents down [NAME] Road. I passed

the facility and went there. I spoke to EMS. They said the residents were ok and will monitor their vitals, so I returned to the facility to do a head count, using the census, everybody was there. EMS brought the residents back about 15 minutes later. They were gone for approximately an hour. The sidewalk terminates so they either walked on grass or the road.

During an interview on 08/13/24 at 11:32 AM, the Administrator stated, I arrived here about 9:40 PM, after I got a call from the ADON. She reported to me that [Resident R2 and Resident R3] were missing, that they had not seen them. I asked if they searched that whole building. I was told no. I instructed her to tell them to search everywhere.

They were located about a mile down the road. I drove down to where they were located to be sure of the distance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 During an interview on 08/13/24 at 12:10 PM, Certified Nurse Assistant (CNA)1, who was assigned to both residents, stated, I answered the doorbell, I thought it was my pizza. But it was two residents who were Level of Harm - Immediate returning from outside and told me they saw two ladies outside. I immediately went to the hall I was working jeopardy to resident health or on, they were not there. I went to the nurse. He was from agency. He said, I let two ladies out of this door a safety little while ago, that was about 8:30 PM - 8:45 PM. I figured I'd let them out to smoke and they'd be right back. He said they looked like they could be allowed outside, they looked competent. I said what two ladies, Residents Affected - Few one with a walker and one with sunglasses on and he said yes. I knew that was them. After that, I asked are

they still out there. I walked outside and I didn't see them and started walking around the building. I grabbed

a CNA from another hall and the hospitality aid who was out in the courtyard with the smokers. I went back to

the nurse and told him I couldn't find those residents outside. I said I think we need to call a code or call someone. He said, I am not calling anybody until you check everybody in the facility. We then did that. I went back and informed him they were not there. The nurse on the other unit called the ADON and reported it to her. That's when the ADON said she was coming in. We went back outside and looked for the two ladies. There's another facility to the left of the building and two CNA's went that way to see if they were there. Then I saw an EMS truck go by, we followed them. I went with another CNA and followed the fire truck, ambulance and cop car. We followed them about a mile and a half or so. We saw them pulled over and the two residents were there. EMS said they are fine, it's just hot. We are going to take their vitals. The officer said someone had called it in, they drove by and saw them. It was about 1.5 - 2 miles away. [Resident R2] was wearing a tee shirt and capri's with tennis shoes, [Resident R3] had on a long sleeve shirt and pants with her ballerina slipper like shoes,

she was very hot, sweating so bad. Her heart rate was 180, that is what EMS said.

During an interview on 08/13/24 at 1:18 PM, CNA2 stated, I worked on Sunday on the 3 - 11 shift. I was working on station 1. One of the residents came to me and told me two of the ladies got out. I went outside to scope and see. I saw some other CNAs out there. We told the nurses. I got in my car and drove onto [NAME] Road to the right and didn't see them, so I went the opposite way and didn't see them. I guess I didn't go far enough because I didn't see them.

During an interview on 08/13/24 at 2:04 PM, Resident R7 stated, We just got back from the store. We seen [Resident R2 and Resident R3] coming out the back door. They walked the property. They went toward the entrance and never came in. I went to the street, and I didn't see them. I rang the doorbell and the nursing assistant answered. We told her about the two ladies we saw. She went to their rooms and didn't see them. I went to the nurse to tell him. I didn't see who let them out.

On 08/14/24, the facility provided an acceptable IJ Removal Plan, which included the following:

Residents #2 and #3 returned to the facility on [DATE REDACTED]. Residents were assessed by the Assistant Director of Nursing on 8/11/24. No injuries identified . Social Services assessed residents for emotional distress on 8/13/24 and referrals made as indicated . Agency Nurse was sent home on 08/11/24 and agency notified for

this nurse to not return to this facility.

Elopement risk Assessments were completed on 8/12/24 . Those residents identified at risk had interventions initiated and care plan updated by 8/13/24.

Facility staff were reeducated on Elopement Policy by the Director of Nursing/Designee on 8/12/24 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 Facility staff were reeducated on Abuse, Neglect, & Misappropriation by the Administrator/Designee on 8/14/24 . Level of Harm - Immediate jeopardy to resident health or Facility staff not receiving this education by the target date will receive prior to their next scheduled shift. safety Agency staff will be educated on the Elopement Policy and Abuse, Neglect & Misappropriation policy prior to Residents Affected - Few their first assignment .

An elopement drill will be completed by 8/14/24 on each shift .

Director of nursing/Designee will interview a minimum of 5 staff members per week for 4 weeks to validate transfer of knowledge.

The Administrator/Designee will interview a minimum of 5 residents per week for 4 weeks to validate residents feel safe and have no care concerns.

The Director of Nursing/Designee will observe care and interactions of staff members with 3 residents per week for 4 weeks to validate residents feel safe and there is no care concerns.

Any identified issues will be addressed at time of discovery.

Ad Hoc QAPI was held on 8/14/24 to review the contents of this plan.

The Medical Director was notified on 8/14/24 of the immediate Jeopardy and the contents of this plan.

AOC date: 8/15/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48835 safety Based on interviews, record review and review of facility policy, the facility failed to provide appropriate Residents Affected - Few supervision to prevent Resident (R)2, and (R)3's elopement from the facility.

On 08/13/24 at 6:31 PM, the Administrator was notified that the failure to properly supervise two residents, resulting in the two residents successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at

F-F689, constituting substandard quality of care.

Findings include:

Review of the facility policy titled Elopement dated 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Once is it determined that a patient/resident is missing, all employees are notified immediately by paging overhead, and it was blank but states, insert code name.

Review of the facility policy titled Accident/Incident Reporting - Patient/Resident stated, An accident is an unexpected, unintended event that can result in bodily injury.

Review of Resident R2's Face Sheet revealed Resident R2 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder.

Review of Resident R2's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/24, revealed Resident R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating Resident R2 was severely cognitively impaired. Under the section behaviors, it recorded Resident R2 as wandering daily.

Review of Resident R2's Elopement assessment dated [DATE REDACTED], indicated Resident R2 was not oriented to her surroundings, and she is confused. Additionally, Resident R2 has a history of wandering and requires supervision, intervention, and wander guard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 Review of Resident R2's Physician Orders revealed an order dated 11/22/22, which revealed to have a wander guard

on at all times, check function and placement every shift. Level of Harm - Immediate jeopardy to resident health or Review of Resident R2's Care Plan dated 06/18/24, revealed Resident R2 was an elopement risk, requiring wander guard on safety wrist and will wander safely within the facility with no elopement attempts.

Residents Affected - Few Review of Resident R3's Face Sheet revealed Resident R3 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to, vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease.

Review of Resident R3's Admission MDS with an ARD of 09/20/22, revealed Resident R3 had a BIMS score of 6 out of 15, indicating Resident R3 was severely cognitively impaired.

Review of Resident R3's Elopement assessment dated [DATE REDACTED], revealed a diagnosis of vascular dementia, not oriented to place or time, has a history of wandering and states Resident R3 does not have a diagnosis that requires supervision. The intervention listed was a wander guard.

Review of Resident R3's Physician Orders dated 09/14/22, revealed an order to monitor for function and placement of wander guard every shift.

Review of Spartanburg Weather for the date of 08/11/24, recorded a high temperature of 87 degrees Fahrenheit and a low temperature of 71 degrees Fahrenheit with no precipitation.

Review of a statement provided by Registered Nurse (RN) on 08/11/24 at approximately 9:00 PM, revealed Resident R2 and Resident R3 were let out the back door by the RN, on duty along, with other smokers with no escort or supervision. The RN's written statement reported, . [Resident R2 and Resident R3] verbalized attention to smoke and were last visualized at 2100 . Residents returned at approximately 2145.

During an interview on 08/13/24 at 10:45 AM, the Assistant Director of Nursing (ADON) stated, I got a call from a nurse at the facility around 9:03 PM on 08/11/24, to report two residents were missing from Unit 2 and

she couldn't find the nurse. She couldn't give me much information, so I got in my car and headed to the building. The [RN] called me to tell me they were missing as I was on the phone with 3 CNA's [Certified Nursing Assistants] on speaker, who were out looking for them. I heard the CNA say, Lets follow EMS as

they passed the facility. They did and said they had found the two residents down [NAME] Road. I passed

the facility and went there. I spoke to EMS. They said the residents were ok and will monitor their vitals, so I returned to the facility to do a head count, using the census, everybody was there. EMS brought the residents back about 15 minutes later. They were gone for approximately an hour. The sidewalk terminates so they either walked on grass or the road.

During an interview on 08/13/24 at 11:32 AM, the Administrator stated, I arrived here about 9:40 PM, after I got a call from the ADON. She reported to me that [Resident R2 and Resident R3] were missing, that they had not seen them. I asked if they searched that whole building. I was told no. I instructed her to tell them to search everywhere.

They were located about a mile down the road. I drove down to where they were located to be sure of the distance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 During an interview on 08/13/24 at 12:10 PM, Certified Nurse Assistant (CNA)1, who was assigned to both residents, stated, I answered the doorbell, I thought it was my pizza. But it was two residents who were Level of Harm - Immediate returning from outside and told me they saw two ladies outside. I immediately went to the hall I was working jeopardy to resident health or on, they were not there. I went to the nurse. He was from agency. He said, I let two ladies out of this door a safety little while ago, that was about 8:30 PM - 8:45 PM. I figured I'd let them out to smoke and they'd be right back. I asked are they still out there. I walked outside and I didn't see them and started walking around the Residents Affected - Few building. I grabbed a CNA from another hall and the hospitality aid who was out in the courtyard with the smokers. I went back to the nurse and told him I couldn't find those residents outside. I said I think we need to call a code or call someone. He said, I am not calling anybody until you check everybody in the facility. We then did that. I went back and informed him they were not there. The nurse on the other unit called the ADON and reported it to her. That's when the ADON said she was coming in. We went back outside and looked for the two ladies. There's another facility to the left of the building and two CNA's went that way to see if they were there. Then I saw an EMS truck go by, we followed them. I went with another CNA and followed the fire truck, ambulance and cop car. We followed them about a mile and a half or so. We saw them pulled over and the two residents were there. EMS said they are fine, it's just hot. We are going to take their vitals. The officer said someone had called it in, they drove by and saw them. It was about 1.5 - 2 miles away. [Resident R2] was wearing a tee shirt and capri's with tennis shoes, [Resident R3] had on a long sleeve shirt and pants with her ballerina slipper like shoes, she was very hot, sweating so bad. Her heart rate was 180, that is what EMS said.

During an interview on 08/13/24 at 1:18 PM, CNA2 stated, I worked on Sunday on the 3 - 11 shift. I was working on station 1. One of the residents came to me and told me two of the ladies got out. I went outside to scope and see. I saw some other CNAs out there. We told the nurses. I got in my car and drove onto [NAME] Road to the right and didn't see them, so I went the opposite way and didn't see them. I guess I didn't go far enough because I didn't see them.

During an interview on 08/13/24 at 2:04 PM, Resident R7 stated, We just got back from the store. We seen [Resident R2 and Resident R3] coming out the back door. They walked the property. They went toward the entrance and never came in. I went to the street, and I didn't see them. I rang the doorbell and the nursing assistant answered. We told her about the two ladies we saw. She went to their rooms and didn't see them. I went to the nurse to tell him. I didn't see who let them out.

On 08/14/24, the facility provided an acceptable IJ Removal Plan, which included the following:

Residents #2 and #3 returned to the facility on [DATE REDACTED]. Residents were assessed by the Assistant Director of Nursing on 8/11/24. No injuries identified . Social Services assessed residents for emotional distress on 8/13/24 and referrals made as indicated .

Agency Nurse was sent home on 08/11/24 and agency notified for this nurse to not return to this facility.

Elopement risk Assessments were completed on 8/12/24 . Those residents identified at risk had interventions initiated and care plan updated by 8/13/24.

Facility staff were reeducated on Elopement Policy by the Director of Nursing/Designee on 8/12/24 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 425303 Department of Health & Human Services Printed: 09/13/2025 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 425303 B. Wing 08/14/2024

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

Lake Emory Post Acute Care 59 Blackstock Road Inman, SC 29349

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 Facility staff not receiving this education by the target date will receive prior to their next scheduled shift.

Level of Harm - Immediate Agency staff will be educated on the Elopement Policy and Abuse, Neglect & Misappropriation policy prior to jeopardy to resident health or their first assignment . safety

An elopement drill will be completed by 8/14/24 on each shift . Residents Affected - Few Director of nursing/Designee will interview a minimum of 5 staff members per week for 4 weeks to validate transfer of knowledge.

Ad Hoc QAPI was held on 8/13/24 to review the contents of this plan.

The Medical Director was notified on 8/13/24 of the immediate Jeopardy and the contents of this plan.

AOC date: 8/14/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 425303