Inspection Reports for Life Care Center of Hilton Head

The complaint involved Resident R56 exposing himself and masturbating in front of Resident R26. Both residents had severe cognitive impairment. The facility initially failed to protect R26 and delayed reporting the incident to the State Agency until seven days after the event. The facility conducted investigations, skin assessments, and implemented 1:1 supervision for R56. The Immediate Jeopardy was removed after corrective actions were validated.

The facility failed to protect Resident R26 from sexual abuse by Resident R56, who was observed masturbating in front of R26. Immediate Jeopardy was identified and later removed after corrective actions. The facility also failed to report the allegation of abuse to the State Agency in a timely manner, reporting it seven days after the incident.

The complaint investigation was triggered by an incident on 07/09/2025 where Resident R56 was observed masturbating in front of Resident R26. The facility was notified of the allegation on 07/09/2025 but did not report it to the State Agency until 07/16/2025. The investigation found no physical contact or trauma, but the incident was classified as sexual abuse due to exposure. Immediate Jeopardy was declared and later removed after corrective actions including 1:1 supervision and staff education.

The facility was found to have failed to protect a resident from sexual abuse by another resident, resulting in immediate jeopardy which was later removed after corrective actions. Additionally, the facility failed to timely report the abuse allegation to the State Agency. Other deficiencies included failure to accurately measure nutritional supplements, failure to provide scheduled bathing and nail care to residents, and failure to securely store medications and remove expired medications.

The facility was found deficient in accurately documenting advance directives for a resident, timely revising care plans to reflect changes in resident condition and refusals of care, providing adequate assistance with activities of daily living, securing medications properly, ensuring physician supervision of pressure ulcers, and following infection control standards during wound care.

The complaint involved an altercation between Resident #4 and Resident #5 over a television remote control, resulting in a physical altercation where Resident #4 sustained a bleeding lip. The facility did not notify the state survey agency within the required 2-hour timeframe but did notify within 24 hours. Neither resident wished to file charges or seek emergency care.

The facility failed to report an allegation of abuse timely for one allegation involving two residents who had a physical altercation over a TV remote. Both residents sustained minor injuries and refused emergency care. The incident was reported to the state survey agency after the required 2-hour timeframe. The facility separated the residents and took corrective actions to prevent further incidents.

The complaint investigation focused on issues including inaccurate resuscitation code status documentation, inadequate staff competency in oxygen administration, lack of documented rationale for declining pharmacy recommendations, failure to quarantine unvaccinated residents and enforce PPE, and improper catheter bag placement.

The facility failed to maintain accurate resuscitation code status documentation for one resident, failed to provide competency training for oxygen administration to a CNA resulting in improper oxygen canister management, did not ensure documented rationale for declining pharmacy recommendations for unnecessary medications, failed to quarantine an unvaccinated resident and enforce PPE use, and allowed a catheter bag to be placed on the floor increasing infection risk.