Bishop Gadsden Episcopal Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, South Carolina.
- Location
- 1 Bishop Gadsden Way, Charleston, South Carolina 29412
- CMS Provider Number
- 425411
- Inspections on file
- 15
- Latest survey
- April 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bishop Gadsden Episcopal Health Care Center during CMS and state inspections, most recent first.
Two residents with urinary catheters had discrepancies between their physician orders and care plans regarding catheter balloon size. One resident with severe cognitive impairment had a care plan listing a different balloon size than ordered, while another resident with a history of cancer and chronic self-catheterization also had mismatched documentation. Facility policy requires care plans to reflect physician orders, and this inconsistency was confirmed by the Director of Clinical Excellence.
The facility failed to consistently monitor and document the use of a wander guard device for a resident with cognitive impairment and wandering behaviors, with inconsistent records and lack of required daily checks. Additionally, two residents with pain were administered PRN opioid and non-opioid medications without clear physician order parameters or documentation of non-pharmacological interventions, and the care plan did not address opioid use. The Director of Clinical Excellence confirmed these deficiencies in monitoring, documentation, and adherence to policy.
A resident with significant respiratory conditions was observed receiving oxygen at a lower flow rate than prescribed by the physician. Despite orders and care plan interventions specifying 4 L/min during ambulation and 2 L/min at rest, the oxygen concentrator was repeatedly set at only 1 L/min. This discrepancy was confirmed by the DCE during the survey.
The facility did not maintain and operate kitchens in a manner that minimizes the risk of foodborne illness for all 21 residents. Observations included improper food storage, such as unlabeled bags and uncovered mixer bowls, and moisture between stacked pans. Staff were seen handling ready-to-eat foods with contaminated gloves and not following proper handwashing procedures. Additionally, employees were observed without hair restraints, contrary to facility policy. The Certified Dietary Manager acknowledged issues with labeling and monitoring expiration dates, indicating inconsistent adherence to established protocols.
A facility failed to maintain a medication error rate below 5%, resulting in an error rate of 7.67%. An RN mistakenly prepared Fluticasone instead of Azelastine for a resident and administered an incorrect dosage of Azelastine. The resident had been admitted with acute respiratory failure and hypoxia, and the error was acknowledged by the RN after review.
The facility failed to ensure the Medical Director assessed a resident for unnecessary medications, specifically Seroquel, without proper rationale or indication for use. The resident's medical records lacked documentation for the use of the antipsychotic medication, and the Medical Director did not work with the facility to evaluate the continued use of the drug.
Failure to Individualize and Accurately Document Catheter Balloon Size in Care Plans
Penalty
Summary
The facility failed to individualize and accurately document comprehensive care plans for urinary catheter bulb size for two residents who required catheter care. For one resident with severe cognitive impairment and urinary retention, the physician order specified an 18 French catheter with a 5 cc balloon, but the care plan incorrectly listed a 10 cc balloon. For another resident with a history of prostate and bladder cancer, chronic self-catheterization, and intact cognition, the physician order specified a 16 French catheter with a 10 cc balloon, while the care plan referenced a 14 French catheter with a 10 ml balloon. These discrepancies were identified through clinical record review, policy review, and staff interview. Facility policy requires that all physician orders, including specific instructions such as catheter and balloon size, be accurately documented and reflected in the resident's care plan. The care plans are to be developed by an interdisciplinary team and must include measurable goals and timetables based on the comprehensive assessment. The Director of Clinical Excellence confirmed that the care plan should match the physician order for catheter balloon size, as this is a standard of care. The failure to ensure consistency between physician orders and care plans for catheter care was observed for both residents reviewed.
Failure to Monitor Wander Guard and Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to monitor and document the use of a wander guard device according to professional standards for a resident assessed at risk for wandering. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, dementia, and depression, was identified as severely cognitively impaired and exhibited wandering behaviors. Although the care plan and facility policy required daily checks for the placement and function of the wander guard, as well as skin checks for irritation, documentation was inconsistent. Clinical records showed alternating documentation of the device being present or absent on various days, and there was no evidence of daily checks or skin assessments as required. The Director of Clinical Excellence confirmed that the physician's order for the wander guard was not obtained in a timely manner and that documentation was inaccurate, with no evidence of adherence to policy or care plan interventions. The facility also failed to provide care and services consistent with professional standards for pain management for another resident with a history of fractures and malignancy, who was cognitively intact and reported frequent pain. The care plan included interventions for pain assessment and medication administration, but physician orders for both opioid (Tramadol) and non-opioid (Tylenol) pain medications lacked specific parameters for use. Nursing staff administered PRN Tramadol on most days, sometimes multiple times per day, and also administered Tylenol for similar pain scores, without clear guidance on which medication to use for specific pain levels. Documentation did not include non-pharmacological interventions prior to opioid administration, and the care plan did not address the use of opioid medication. Interviews with the Director of Clinical Excellence confirmed that the facility did not clarify physician orders for pain medications, did not document non-pharmacological interventions prior to opioid use, and did not follow facility policy or accepted standards of practice for pain management. The lack of clear parameters for medication administration and incomplete documentation contributed to the deficiencies identified in the management of both the wander guard device and pain control.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary manifestations due to radiation, pneumonia, and influenza. The resident's care plan and physician orders specified oxygen administration via nasal cannula at 4 liters per minute during ambulation and 2 liters per minute at rest. However, during multiple observations, the resident was found sitting in a wheelchair in their room with the oxygen concentrator set at only 1 liter per minute, which was not consistent with the prescribed orders. These observations were confirmed on three separate occasions, including one in the presence of the Director of Clinical Excellence, who acknowledged that the physician's order for supplemental oxygen was not being followed. The clinical record and care plan documentation supported the need for specific oxygen settings, but staff did not adhere to these requirements during the survey period.
Kitchen Safety and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to ensure the kitchens were maintained and operated in a safe manner to minimize the chances for potential spread of foodborne illness to all 21 residents. Observations revealed various deficiencies, including improper food storage, handling ready-to-eat foods with contaminated gloves, failure to air dry pans and containers before storage, and lack of employee hair restraint in the kitchens. Policies related to storing staples, perishable food items, sanitary conditions, labeling, hair restraints, and food preparation and handling were found to be in place, but not consistently followed by staff. During kitchen tours, instances of improper food storage were noted, such as unlabeled bags of food, uncovered mixer bowls, and moisture between stacked pans and containers. Employees were observed not following proper handwashing procedures and using contaminated gloves to handle food. Additionally, staff members were seen without hair restraints while working in the kitchen, which is a violation of the facility's policy. The Certified Dietary Manager acknowledged deficiencies in labeling and expiration date monitoring of food items, indicating a lack of adherence to established protocols.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an error rate of 7.67% during a medication pass observation for one of three residents. Specifically, a registered nurse (RN1) was observed preparing to administer Azelastine Nasal Spray to a resident (R224) but mistakenly took a container of Fluticasone Nasal Spray from a pharmacy-labeled Azelastine vial. The surveyor intervened, and RN1 acknowledged the error, stating that the wrong medication had been placed in the vial by the pharmacy. Despite this, RN1 proceeded to administer the correct medication, Azelastine, but gave an incorrect dosage of two sprays per nostril instead of the prescribed one spray per nostril twice a day for allergic rhinitis, unspecified. The resident, R224, had been admitted to the facility with diagnoses including acute respiratory failure with hypoxia. During the medication reconciliation process, it was confirmed that the resident had orders for both Azelastine and Fluticasone nasal sprays, but the administration of Azelastine was not in accordance with the prescribed dosage. RN1 admitted to the error after reviewing the medication administration record and the medications for R224. This incident highlights a failure in the medication administration process, leading to a higher than acceptable medication error rate in the facility.
Failure to Assess Unnecessary Medications
Penalty
Summary
The facility failed to ensure the Medical Director worked with the facility to completely assess a resident for unnecessary medications. Specifically, an antipsychotic and psychoactive medication, Seroquel, was used without an attempted gradual dose reduction, proper medical rationale, or proper indication for use. The facility's policy requires the Medical Director to supervise medical care and ensure compliance with regulations, but this was not followed in the case of the resident. The resident's medical records did not indicate a psychiatric or mood diagnosis, nor did they document the physician's rationale for prescribing Seroquel or any behaviors or psychosis that would justify its use. The resident was admitted with diagnoses including pneumonia, normal pressure hydrocephalus, and unspecified dementia. Despite these conditions, the resident's Minimum Data Set did not indicate a need for psychotherapeutic agents. The facility's Administrator and Director of Nursing confirmed that the Medical Director did not work with the facility to assess the continued use of Seroquel, citing a reluctance to alter long-standing psychotherapeutic medication orders during a short-term stay. Attempts to contact the Medical Director were unsuccessful, and the resident's care plan did not reference the specific medication, highlighting a significant oversight in the resident's medical management.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
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