Saint Matthews Health Care, Llc

F-F689, constituting substandard quality of care.

Findings include:

Review of the facility's policy titled Elopement last revised 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment.

Review of Resident R1's Face Sheet revealed Resident R1 was admitted to the facility on [DATE REDACTED], 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 Resident R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/08/24, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating Resident 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 3 425170 Department of Health & Human Services Printed: 09/23/2025 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 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

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 0689 Review of Resident R1's Elopement Risk Tool dated 05/02/24, revealed Resident R1 is not alert and oriented. Resident R1 is confused and does not have safe decision-making capabilities. Resident R1 has a history of wandering and has previously Level of Harm - Immediate attempted to leave the health care center. Further review revealed, Resident R1 has diagnoses that requires jeopardy to resident health or supervision. safety

Review of Resident R1's Physician Orders dated 08/01/23, revealed the following order, Wander guard to right ankle; Residents Affected - Few check placement and function Q shift.

Review of Resident R1's Progress Note dated 06/11/24 at 7:21 PM, revealed, At 6:30 resident attempt to go out of building doors was opened, but I the nurse and staff re-direct her back into the building.

Review of Resident R1's Progress Note dated 06/11/24 at 9:32 PM revealed, At 7.18pm this nurse was in the med room. when i got out of the med room I saw other nurses running towards the back door. This nurse left the stuff she was carrying in the cart and rushed to where the other nurses where running to. Upon going out,

this nurse saw that it was her resident who was on the ground. Assessment done on resident she reported

she hit her head .

During an interview on 06/14/24 at 11:59 AM, Licensed Practical Nurse (LPN)1 stated that on the night of 06/11/24 at approximately 7:15 PM, the door alarm/wander guard system alarm went off, LPN1 then went to check the panel to see which door it was, it was 2B, LPN1 then went down the hall, however it was the wrong hall. LPN1 then went down E hall and out the door and found Resident R1 lying on the ground in the parking lot next to a light pole. LPN1 states that Resident R1 reported to her that she fell and hit her head. 911 was then called for Resident R1.

During an interview on 06/14/24 at 12:09 PM, Resident R1 stated that she wanted to go to the white house across the street, so just got up and walked out the door. Resident R1 further stated that she fell in the parking lot on a curb and hit her head and was sent to the emergency room .

During an interview on 06/14/24 at 12:45 PM, LPN2 stated that Resident R1 was wearing a white top, pink pants and non-slip socks, when she was found in the parking lot.

According to the Weather Channel, on 06/11/24, the high was 89 degrees Fahrenheit with a low of 63 degrees Fahrenheit.

On 06/14/24 at approximately 2:18 PM, the facility provided a removal plan, which included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 425170 Department of Health & Human Services Printed: 09/23/2025 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 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

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 0689 Resident Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution. Elopement risk evaluation repeated. Resident had Wandergard in place and properly functioning at time of incident. MD/RP Level of Harm - Immediate notified. Administrator and CSD notified of incident. Residents at risk of elopement have the potential to be jeopardy to resident health or affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by safety nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions. All doors check for auditory alarm; found to be in working order. Educate facility staff the expectation that if a Residents Affected - Few door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents. If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management. Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. Staff will be reeducated on appropriate response to alarms. This re-education will be initiated on 06/11/2024 and completed by 06/12/2024. Any member of target audience not receiving this by this date will receive prior to next scheduled shift. New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process. The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly. The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance. Ad hoc QAPI held on 06/12/2024. Medical Director was notified of the incident and plan for improvement on 06/12/2024. This process will be reviewed in QAPI for a minimum of 3 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 425170