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Complaint Investigation

Lake Emory Post Acute Care

August 14, 2024 · Inman, SC · 59 Blackstock Road
Citations 5
CMS Rating 1/5
Beds 88
Provider ID 425303
Healthcare Facility
Lake Emory Post Acute Care
Inman, SC  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Lake Emory Post Acute Care in Inman, SC — inspection on August 14, 2024.

Found 5 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

FF0580
Immediately tell the resident, the resident's doctor, and a family member of situations

During an interview on 08/13/24 at 2:38 PM, R3's Guardian (court appointed) stated, I am the first point of contact for [R3]. I work for an advocacy group. I am not aware she got out and was walking down the street at night. I've not been notified at all.

During an interview on 08/13/24 at 4:00 PM, the Administrator stated, For investigations regarding elopement we start the investigation as soon as possible. I don't call the Responsible Party, the nurses usually make that call, not me.

During the investigation period, I will ask if someone notified the Responsible Party.

There are times when I may have forgotten to give the information.

The Administrator confirmed there was no documentation in R2's or R3's record that the responsible party had been notified.

425303 08/14/2024

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

residents feel safe and have no care concerns.

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

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

425303 08/14/2024

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

jeopardy to resident health or safety The Medical Director was notified on 8/13/24 of the immediate Jeopardy and the contents of this plan.

AOC date: 8/14/24

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

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

Under the section behaviors, it recorded R2 as wandering daily.

Review of R2's Elopement assessment dated [DATE], indicated R2 was not oriented to her surroundings, and she is confused.

Additionally, R2 has a history of wandering and requires supervision, intervention, and wander guard.

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

425303

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 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

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

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

Under the section behaviors, it recorded R2 as wandering daily.

Review of R2's Elopement assessment dated [DATE], indicated R2 was not oriented to her surroundings, and she is confused.

Additionally, R2 has a history of wandering and requires supervision, intervention, and wander guard.

425303

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 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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Inman, SC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Lake Emory Post Acute Care or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.