Saint Matthews Health Care, Llc

F-F880 at a lower scope and severity of D.

Findings include:

Record review of facility policy titled Staff Education/Orientation Policies and Procedures Blood Glucose Monitoring last revised 01/12/24 revealed reference facility specific Blood Glucose Monitoring Device manufacturer's recommendations. Clean Glucometers utilizing two-step process with an approved Environmental Protective Agency (EPA) disinfectant wipe which is labeled effective against Tuberculosis (TB), or Hepatitis B Virus (HBV), Hepatitis C (HCV), or Human Immunodeficiency Virus (HIV) to remove any visible contaminants, soil, or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.

Record review of facility policy Infection Prevention and Control Policies and Procedures Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), last revised 05/15/23 revealed EBP will be implemented for all residents with the following: infection or colonization with a Multidrug-resistant Organisms (MDRO) when contact precautions due not otherwise apply; wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.

Record review of the Manufacturer's recommendation for the Evencare G2 Meter revealed Cleaning and disinfecting the meter is very important in the prevention of infectious disease. The following products are validated for disinfecting the EVENCARE G2 Meter ., .Medline Micro-Kill Bleach Germicidal Bleach Wipes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 425170 Department of Health & Human Services Printed: 09/03/2025 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 03/26/2025

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 0880 During a medication administration observation on 03/24/2025 at 5:20 PM with Registered Nurse (RN)1. She stated each resident has an individual glucometer. She pulled Resident R86's pouch from the medication cart. The Level of Harm - Immediate glucometer was not located in the pouch. She checked some of the other pouches and said Resident R168's jeopardy to resident health or glucometer was not in his pouch either. She then looked in the drawers of the medication cart and found a safety glucometer and said this was Resident R86's blood sugar check machine (finger stick blood sugar). She found an Even Care G2 glucometer. It did not have Resident R86's name on it. RN1 said she checked her blood sugar this am. Residents Affected - Few It was 153 at lunch. She wiped the machine with an alcohol prep pad and entered Resident R86's room to perform the blood sugar checks check. She then returned to the medication cart afterward. She cleaned the glucometer with an alcohol prep pad. She returned the pouch back into the medication cart.

Observation on 3/24/25 at 5:50 PM, Licensed Practical Nurse (LPN) 1 was observed placing an Evencare G2 glucometer into a pouch. LPN1 stated she had just finished checking a resident's blood sugar and had cleaned it with an alcohol wipe since all residents have their own glucometer.

During an interview on 3/24/25 at 5:54 PM, LPN2 described how she cleans the Evencare G2 glucometers stating that she uses MicroKill Bleach Wipes even though each resident has their own glucometer.

On 03/24/2025 at 5:55 PM RN1 opened the medication cart. She opened each pouch and pulled the machine from the pouch to verify who had a glucometer. Resident R168 and Resident R67 did not have a glucometer in their pouches. When asked if she performed a blood sugar check on either of these residents, she stated, I had to do a blood sugar checks check earlier on Resident R168, around noon. I used Resident R86's blood sugar checks machine for him. I always clean with an alcohol pad, with each person. His blood sugar was 279.

Record review of Resident R86's Face Sheet revealed she was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to type 2 diabetes mellitus, binge eating disorder, and morbid obesity.

Record review of Resident R86's quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview Mental Status (BIMS) score of 15, of 15, indicating she was cognitively intact.

Record review of Resident R168's Face Sheet revealed he was admitted on [DATE REDACTED] with diagnoses including but not limited to: orthopedic aftercare following surgical amputation.

Record review of Resident R168's MDS admission MDS with an ARD date of 03/18/25 revealed a BIMS score of 15, of 15, indicating he was cognitively intact.

Record review of Resident R168's MAR dated 03/24/25 at 12:30 PM indicated that a blood sugar check was performed, with a result of 279 mg/dL.

Record review of Resident R67's Face Sheet revealed Resident R67 was admitted to the facility on [DATE REDACTED] with the diagnoses including but not limited to: type 2 diabetes mellitus with hyperglycemia, hypertension, pain, and schizophrenia.

Record review of Resident R67's quarterly MDS with an ARD of 03/14/25 revealed a BIMS score of 12 of 15 which indicates he is moderately impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 425170 Department of Health & Human Services Printed: 09/03/2025 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 03/26/2025

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 0880 Record review of Resident R67's Medication Administration Record (MAR) dated 03/24/25 at 12:00 PM, indicated that

a blood sugar check was performed, with a result of 106 mg/dL. Level of Harm - Immediate jeopardy to resident health or During an interview 03/25/25 at 08:23 AM, the Director of Nursing (DON) said, for glucometer cleaning, wash safety hands, don gloves. Inspect the glucometer to see it is visibly soiled, wipe with an alcohol pad, then use Environment Protection Agency (EPA) approved germicidal wipes, wash hands, don gloves, place barrier Residents Affected - Few down and place glucometer on it, wet it down, with blue top for 3 minutes. Each patient has their own glucometers, we have extras in the supply room. If they don't have one, we have replacements. She said it is not ok for a nurse to use another resident's glucometer; each resident has their own. In the room, they should transport the glucometer in a cup and or place a barrier down at bedside. Each resident has their own clear pouch. The Unit Manager audits the carts every Monday, making sure each resident has their own glucometer. I made sure we had at least 5 extras in the supply room.

During an interview on 03/25/25 at 10:48 AM RN2 stated, Resident R188 has a wound vac and is not on EBP.

During an interview on 03/25/25 at 11:05 AM, LPN4 stated Resident R86 should be on EBP and should have an order for it. She also confirmed Resident R168 should have EBP signage on his door and an order for it as well.

The facility's removal plan dated 03/26/25 noted the following:

Residents who require blood glucose moitoring will be assessed for signs and symptoms of infection by the licensed nurses on 02/25/2025.

R#188 without negative effects. Resident #168 had EBP implemented on 03/25/2025.

EPA disinfectant wipes were placed in medication carts that store glucometers.

An audit of glucometers was completed by the DON/Designees on 03/25/2025 to validate each resident that requiring blood glucose monitoring has a glucometer available.

A review of current in house residents will be completed by the DON/Designee on 03/25/2025 to identify residents who require EBP which include;

Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions.

Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds.

Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters.

Residents identified as meeting the criteria for EBP will have a signage placed at the door, provider notified and order written, responsible party notified and care plan updated on 03/25/2025.

Licensed nurses will be reeducated with competency validation by the DON on 03/25/2025 on blood glucose monitoring including;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 425170 Department of Health & Human Services Printed: 09/03/2025 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 03/26/2025

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 0880 Validating the residents assigned glucometer is used.

Level of Harm - Immediate Location and availability of additional glucometers. jeopardy to resident health or safety Using a barrier to place the glucometer on if needed in residents room.

Residents Affected - Few Using a 2 step process with an approved EPA disinfectant wipe to remove any visible contaminants, soil or other debris and using a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.

Validating EPA disinfectant is available on their medication cart at the beginning of their shift.

Licensed nurses will be reeducated by the DON on 03/25/2025 on EBP including criteria that required EBP:

Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions.

Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds.

Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters.

Any licensed nurse not receiving this reeducation validation by 03/25/2025 will receive prior to their next scheduled shift. This will be presented in new hire orientation and in Agency orientation.

The DON will randomly observe 2 licensed nurses for 5 days performing blood glucose monitoring to validate proper procedure including infection control technique and correct glucometer is being utilized.

The DON/Designee will validate each morning for 5 days EPA disinfectant wipes and available on each med cart that stores glucometers.

The DON/Designee will review the facility activity report and 24-hour report in the clinical morning meeting Monday-Friday to identify any resident who require EBP and validate orders are written, provider and responsible party are notified, signage on residents door, PPE is available and care plan updated.

On 03/26/2025 at 4:00 PM the removal plan was accepted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 425170