Lake Emory Post Acute Care

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

you talking to me like that? AA stated Resident R47 used his right hand and the first time, he missed. AA stated the second time; he hit her left cheek. She confirmed Resident R47 was aiming at Resident R13. AA stated Resident R47 told her that Resident R13 was cussing at him. AA stated this was the only time she had seen Resident R47 being aggressive with other residents. AA confirmed Resident R47 intended to hit her. During an interview on 08/25/25 at 2:50 PM, the Administrator stated Resident R47 had seizures. She stated he could go from one end to the next with his aggression. She confirmed she had unsubstantiated abuse. She stated she was not aware Resident R47 had tried to hit Resident R13 twice. She confirmed she was the abuse coordinator.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and policy review, the facility failed to report an allegation of staff to resident physical abuse for one of two (Residents (R)18) abuse allegations reviewed in the sample of 21 residents to

the State Agency (SA) immediately, but no later than 2 hours after the allegation was made when the incident involved abuse. This failure had the possibility to negatively impact all 83 residents currently residing at the facility.Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised 11/01/17, indicated, . The facility shall report immediately, but not later than two hours

after the allegation is make if the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result

in serious bodily injury to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Review Resident R18's admission Sheet, found in the electronic medical record (EMR) under the Census tab, revealed Resident R18 was admitted to the facility on [DATE REDACTED] with the diagnoses of Alzheimer's.Review of the facility's investigative file indicated the facility provided Five-Day Follow-Up Report, dated 07/11/25, revealed, .On 07/07/25, after reporting to work at 3:10 PM, Certified Nursing Assistant (CNA)1 and CNA2, notified the Director of Nursing (DON) of an event that they felt may be alleged abuse that occurred on 07/05/25 at approximately 9:15 PM. The CNAs alleged Licensed Practical Nurse (LPN)1 forced Resident R18 to take her medication. The file revealed a body audit was completed on Resident R18 without findings. The responsible party, nurse practitioner, and Sherriff's department were notified of

the allegation. CNA1 and CNA2 were immediately re-educated that any alleged abuse is supposed to be reported immediately. The details of their alleged abuse were taken, and all three staff members were suspended pending investigation. The facility's conclusion of investigation stated, Based on the findings of

the investigation, there is no evidence of willful intent to cause injury or harm, so abuse is not substantiated.

Abuse re-education initiated. No further suspicion of abuse indicated throughout investigation. Ongoing monitoring of Resident R18 will continue. Interventions and care plan updated accordingly and as needed.During an

interview on 08/25/25 at 3:10 PM, the Administrator stated she did not substantiate this abuse allegation due to discrepancies in all three staff members' statements. The Administrator indicated that LPN1 had been terminated for interfering with the investigation.During a follow-up interview on 08/26/25 at 4:15 PM,

the Administrator confirmed CNA1 and CNA2 left work on 07/05/25 without reporting the allegation. The Administrator stated two days after the alleged incident CNA 1 and CNA2 reported the allegation to the DON on 07/07/25.During an interview on 08/26/25 at 11:50 AM, the DON stated CNA1 and CNA2 were new hires and had completed abuse education, they knew to report abuse allegations immediately but failed to do so.

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