Calhoun Convalescent Center

Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, abnormalities of gait and mobility, lack of coordination, difficulty in walking, unsteadiness on feet, reduced mobility, altered mental status, fall from bed, neurocognitive disorder with Lewy bodies, and depression.

Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/08/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R1 was severely cognitively impaired.

Further review of the MDS revealed that wandering behaviors occurred 1 to 3 days.

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

425170

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 425170 B.

Wing 06/14/2024

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

Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135