F-F760, constituting substandard quality of care.
Findings include:
Review of the facility policy titled Reconciliation of Medications on Admission with a last revision date of July 2017, revealed, General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 Review of the facility policy titled Medication Regimen Review with a last revision date of May 2019, revealed, Policy Interpretation and Implementation . 4. The goal of the MRR is to promote positive outcomes Level of Harm - Immediate while minimizing adverse consequences and potential risks associated with medication. 9. An irregularity jeopardy to resident health or refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of safety practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without Residents Affected - Few adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 10. If the identified irregularity represents a risk to a person's life, health, or safety, the Consultant Pharmacist contacts
the physician immediately (within one hour) to report the information to the physician verbally and documents
the notification.
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 Resident R43's Face Sheet revealed Resident R43 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: cerebral infarction, depression, and anxiety.
Review of Resident R43's unspecified Minimum Data Set, dated dated dated [DATE REDACTED], revealed the resident had an active diagnoses of depression and anxiety disorder. Further review of the MDS indicated Resident R43 was receiving antianxiety and antidepressant medications.
Review of Resident R43's Discharge Summary from a (local hospital) dated 03/04/25, revealed Resident 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 Resident R43 revealed that on 02/28/25 and on 03/11/25, Resident 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 Resident 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 Resident R43's Medication Administration Record (MAR) revealed, Bupropion 300 mg 24 hour tablet, extended release every 8 hours was administered to Resident R43 on the following dates: on 03/04/25-Resident R43 received 1 dose of medication at 10:00 PM. On 03/05/25-Resident R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/06/25-Resident R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/07/25-Resident R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/08/25-Resident R43 received 1 dose of medication at 6:00 AM.
Review of Resident R43's Treatment Administration Record (TAR) did not reveal an order or documentation for antidepressant side effect monitoring.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 During an interview with Resident R43's Resident Representative (RP) on 05/20/25 at 4:47 PM, revealed Resident R43 was admitted on [DATE REDACTED]th, and over the following days the family noticed that Resident R43 was more groggy and sleepier Level of Harm - Immediate than normal. The RP stated that he reported the new finding to the Nurse Practitioner (NP)1 and asked if jeopardy to resident health or maybe her medications is causing Resident R43 excessive sedation. NP1 told the RP that the medications were safety correct in the system. The RP revealed NP1 provided the RP with a copy of the current medications Resident R43 was taking. The RP then went to Resident R43's Primary Care Provider (PCP) and requested a copy of Resident R43's medication Residents Affected - Few list prior to her admission to the nursing home. After comparing the two-medication lists, the RP discovered that there was a discrepancy in Resident R43's Wellbutrin dose. The RP revealed that while in the facility, the resident was receiving Wellbutrin 300 mg every 8 hours, on the other hand, the medication list from the PCP revealed Resident R43 should have only been receiving Wellbutrin 300 mg 1 time every 24 hours. After the discovery was made, the RP revealed he called NP1 immediately. The RP stated NP1 called poison control to report the incident and that poison control recommended they send the resident out to the hospital for further evaluation and monitoring. The RP further stated Resident R43 spent a few days at the hospital for close monitoring.
The RP concluded Resident R43's medication has since been corrected and Resident R43's mentation was drastically improved.
During an interview with Licensed Practical Nurse (LPN)1 on 05/20/25 at 5:36 PM, revealed her role during medication reconciliation process during admission is as follows: If a resident is coming in from another facility or hospital, the pharmacy team will put the residents' medication orders into the system and the floor nurse will verify and activate the orders. LPN1 stated the pharmacy team only puts the name and dosage of
the drug, and the floor nurses verify the medication orders and will put in the medication frequency, times, and route. LPN1 further stated that she does not remember putting in Resident R43's Wellbutrin orders, as the incident happened in March and that she is only PRN (as needed). LPN1 revealed if the system states that
she was the one who input the order on the resident chart, then it was possible that she may have put in the incorrect order. LPN1 stated that she does not just pull random orders out of thin air and that if she put in the order incorrectly, then the must have gotten the order from somewhere. LPN1 concluded that she was not in
the facility when Resident R43 went out to the hospital, nor did she know of Resident R43's hospitalization regarding the resident's level of consciousness change.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 During an interview with the Director of Pharmacy Operations (DPO) on 05/20/25 at 5:50 PM, revealed that
the pharmacy's role regarding the medication reconciliation process during admission is as follows: If the Level of Harm - Immediate facility is admitting a resident from another facility or the hospital, a staff member from the facility will send jeopardy to resident health or over the discharge summary to pharmacy team. The pharmacy team will then have a data entry specialist safety input the medication orders outlined by the provider who wrote the resident's discharge instructions into the system. A Pharmacist will then review the medication orders and verify that the medication orders on the Residents Affected - Few resident chart matches the orders on the resident discharge instructions. A pharmacy technician will then print the medication label and fill the prescription. Lastly, a second pharmacist will verify that the information printed on the medication label matches the resident order. Once the checks have been completed, then the medications will be sent out to the facility. The DPO stated the pharmacy team is only able to put the name of medication and the dose in the resident system, although the pharmacy team cannot put the frequency, time, and route of medication in the system, the pharmacy team then will leave a note on the order with the aforementioned details. The nurse who will activate the orders are the ones ultimately responsible for inputting the frequency, times, and route of administration. The DPO revealed that the order for Resident R43's Wellbutrin was for 300 mg once daily, per the discharge instruction from the (local hospital). The DPO revealed that the order they placed for Resident R43 was for the resident to receive Wellbutrin 300 mg once daily. The DPO continued, the disconnect occurred with whomever the nurse was that activated the orders. The DPO stated that the order for Wellbutrin 300 mg every 8 hours was an error, and that the resident was supposed to receive the Wellbutrin 300 mg once a day. The DPO further stated that when the error was brought to the pharmacy teams' attention, a change in the process was made.
During an interview with the Director of Nursing (DON) on 05/20/25 at 6:10 PM, revealed medication orders are typically placed by pharmacy team on draft. Medications being on draft means, a medication order is not active until a nurse verifies the orders and activates them. The nurse primarily responsible for this role is the nurse caring for the resident. This is a way of providing a second check/verification. The DON stated the resident discharge summary from where they are admitting from is what the facility uses to input and verify resident medication orders. The DON further stated on this particular incident, LPN1 did not follow protocol when reviewing Resident R43's Wellbutrin order on draft. LPN1 placed the medication order on active without following the necessary steps to verify the correct medication order matches the resident discharge summary and medication.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 During an interview with NP1 on 05/21/25 at 9:50 AM, revealed her role in the medication reconciliation process is to review the medication orders from the hospital and compare it to the resident facility Medication Level of Harm - Immediate Administration Record (MAR) and ensure the orders match within a 72-hour window. NP1 revealed that she jeopardy to resident health or was with Resident R43 and family in the resident's room trying to figure out what was making Resident R43 drowsy. NP1 safety revealed she told the RP that she has not gotten to review the resident's MAR. NP1 stated the RP then asked NP1 if they could provide the family with the current medication list at the facility. The RP then Residents Affected - Few compared the list to the resident home medication list and that is when the discrepancy was found. NP1 stated because of this, she and the family worked together to determine the cause of Resident R43's increased drowsiness. Once NP1 was made aware of the discrepancy, NP1 immediately called the poison control center, and poison control recommended to send Resident R43 to the hospital for close monitoring of cardiac arrhythmia. NP1 stated she called the floor nurse and notified her of the situation, and the nurse went through their process of reporting and following up with the NP1's orders. When Resident R43 came back from the hospital, the resident was still slightly confused but mentation was improved. NP1 further stated during Resident R43's time in the hospital, they completed a CT scan and determined the resident had a Cerebrovascular Accident (a medical condition characterized by the sudden interruption of blood flow to the brain, leading to brain damage), the hospital provider was not able to make a determination of when the CVA had occurred. With
the newly found CVA and resident was still a little bit confused on re-admission, but her mentation has improved. NP1 revealed the pharmacy team was to put in the orders as outlined by the discharge instructions and the floor nurses are the ones who accept and activate the orders after verifying that the draft orders match the discharge instructions. The process broke down when the nurse failed verify the orders as evidenced by order being placed incorrectly. NP1 concluded the nurse failed at meeting her expectations regarding following safe procedure when inputting medication orders.
During an interview with the Administrator (LNHA) on 05/21/25 at 11:34 AM, revealed on 03/08/25, Resident R43 was sent to the hospital for altered mental status. Upon investigation, the LNHA and management team conducted an internal investigation where they determined after review of hospital discharge and Resident R43's current medication order, Resident R43 was receiving too many doses of Wellbutrin. The LNHA stated the breakdown that occurred was human error with LPN1. The LNHA revealed LPN1 went out of her way to input the orders
on draft and activated the orders herself without having another nurse verify the order. The LNHA noticed that on the Hospital Discharge Summary 2 (two) medications were listed on top of one another which may have attributed to LPN1's error. The Hospital discharge medication list had the medication BUPROPRION (Wellbutrin) 300 mg 24 hour ER Tablet Daily above the medication BUSPIRONE (Buspar) 10 MG tablet 3 (three) times daily.
During an interview with the Medical Director (MD) on 05/21/25 at 12:50 PM, revealed when a newly admitted patient arrives from the hospital, the process was for the nurse to reconcile medication from the discharge summary and put the orders into the system. The NP, MD and Pharmacy team will then serve as another layer of safety to reconcile the medications to ensure the resident is receiving the correct medication outlined by the discharge summary. The MD stated that he was made aware of the incident with Resident R43, when it was reported to the MD that Resident R43 was receiving an excessive dose of Wellbutrin. The MD stated Resident R43 was receiving Wellbutrin 300 mg 3 times a day instead of Wellbutrin 300 mg 1 time a day. The resident was sent out to the hospital for 3 days for close monitoring. After facility investigation, the MD revealed that the error was made by a member of the nursing staff, where the nurse may have confused the Bupropion/Wellbutrin 300 mg 1 tablet 1-time daily order with the Buspirone 10 mg 3 times daily. The MD stated that due to the similarity of the medications the nurse incorrectly placed the wrong order for Bupropion/Wellbutrin.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 On 05/22/25 the facility provided an acceptable IJ Removal Plan, which included the following:
Level of Harm - Immediate I. Ensuring Harm Will Not Occur or Recur. To prevent the recurrence of pharmacy services medication error jeopardy to resident health or incidents, our facility has taken immediate and ongoing actions to eliminate the risk associated with safety medication errors. These steps include the reassessment of all residents at risk, reinforcement of security measures, and staff education to ensure proper monitoring and response. All actions taken are designed to Residents Affected - Few provide an accident-free environment while ensuring adequate supervision for all at-risk residents.
II. Date of Implementation. While all corrective actions were initiated immediately upon the discovery of the deficiency, the official implementation dates for specific actions are listed below:
3.13.2025 - Facility was in full compliance.
1. March 8, 2025 - Resident was sent to the hospital for evaluation due to altered mental status.
2. March 9, 2025-Review of the incident by the community revealed the resident was receiving wrong dosage of medication.
3. March 12, 2025- Incident review with medical director, contracted pharmacy and nursing staff; new admission procedure implemented.
4. March 12, 2025 - Re-education provided to nurses regarding admission medication order procedures.
5. March 12, 2025 - Nursing staff reviewed all orders for current patients. Nurses enter medications in draft status to review, while a second nurse will verify accuracy and activate orders.
6. March 13, 2025- DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter.
7. Ongoing- Upon admission, each resident medication list is entered by trained pharmacy staff. Receiving nurses will review profiled medications by pharmacy as second check, reconciling with physician order and activating. DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter.
III. Identifying Those Affected or at Risk The resident involved in the medication error incident, along with all residents receiving medications have been identified as at risk. Immediate interventions were implemented for these residents, including reassessment and reinforcement of monitoring protocols to prevent further occurrences.
IV. Systemic Process Changes to Prevent Recurrence The facility has taken the following steps to alter systemic failures and prevent future adverse outcomes:
1. Increased Monitoring and Audits:
a 3.12.2025-DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 425412 Department of Health & Human Services Printed: 08/26/2025 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 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
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 0760 o 5.21.2025: CSA, DON, and/or Designee will conduct audits daily for two weeks, weekly
Level of Harm - Immediate for eight weeks, and monthly for three months or longer until I00% compliance is met to ensure all new med jeopardy to resident health or orders are accurate. All negative findings will be corrected immediately. Involved Team Members will be safety reeducated immediately.
Residents Affected - Few o 5.21.2025: Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations.
2. Enhanced Staff Training and Education:
o 3.12.2025: Nursing staff re-educated on medication admission policies, including the proper use of pharmacy integration and verifying order read back and correctness.
o 5.21.2025: New nurse hires will receive training on proper medication during orientation, and annual refresher training will be conducted for all nurses.
3. Family and Resident Engagement:
o 5.21.2025: Families and residents will be provided education by the facility on the potential of medication errors and facility safety measures.
o 5.21.2025: Family input will be incorporated into individualized care plans to enhance medication error prevention strategies.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 425412