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Health Inspection

Retreat At Wellmore Of Lexington

May 22, 2025 · Lexington, SC · 200 Wellmore Drive
Citations 1
CMS Rating 4/5
Beds 60
Provider ID 425412
Healthcare Facility
Retreat At Wellmore Of Lexington
Lexington, SC  ·  View full profile →
Inspection Summary

Retreat at Wellmore of Lexington in Lexington, SC — inspection on May 22, 2025.

Found 1 citation. 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.

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Inspection Findings

FF760
Immediate while minimizing adverse consequences and potential risks associated with medication. 9. An irregularity Few adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 10. If the affected

Review of the facility policy titled Admission Assessment and Follow Up: Role of the Nurse with a revision date of September 2012, revealed, Steps in the Procedure: 11.

Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from previous institution, according to established procedures.

Review of R43's Face Sheet revealed R43 was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral infarction, depression, and anxiety.

Review of R43's unspecified Minimum Data Set, dated dated dated [DATE], revealed the resident had an active diagnoses of depression and anxiety disorder.

Further review of the MDS indicated R43 was receiving antianxiety and antidepressant medications.

Review of R43's Discharge Summary from a (local hospital) dated 03/04/25, revealed R43's discharge medications from the hospital included: Bupropion (Wellbutrin) 300 mg (milligram) 24 hour ER (extended release) tablet, take 1 tablet (300 mg total) by mouth daily.

Review of the Pharmacy Orders for R43 revealed that on 02/28/25 and on 03/11/25, R43 had an order for Bupropion 300 mg tablet that was coded T1T1D.

According to the key, T1T1D indicates, take 1 tablet by mouth daily.

This was confirmed by the Director of Pharmacy Operations (DPO).

Review of R43's Physician Orders dated 03/04/25 at 5:52 PM, revealed the following order, Bupropion 300 mg 24 hour tablet, extended release every 8 hours at 06:00 AM, 02:00 PM, and 10:00 PM.

Review of R43's Medication Administration Record (MAR) revealed, Bupropion 300 mg 24 hour tablet, extended release every 8 hours was administered to R43 on the following dates: on 03/04/25-R43 received 1 dose of medication at 10:00 PM. On 03/05/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/06/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/07/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/08/25-R43 received 1 dose of medication at 6:00 AM.

Review of R43's Treatment Administration Record (TAR) did not reveal an order or documentation for antidepressant side effect monitoring.

425412

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 425412 B.

Wing 05/22/2025

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

Retreat at Wellmore of Lexington 200 Wellmore Drive Lexington, SC 29072

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 Lexington, 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 Retreat at Wellmore of Lexington or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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