Brushy Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Greer, South Carolina.
- Location
- 101 Cottage Creek Circle, Greer, South Carolina 29650
- CMS Provider Number
- 425004
- Inspections on file
- 23
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 7 (2 serious)
Citation history
Health deficiencies cited at Brushy Creek Post Acute during CMS and state inspections, most recent first.
A resident admitted with a history of hypertensive crisis and other serious conditions had a critically high blood pressure reading that was not communicated to nursing staff or treated as ordered. The resident was not entered into the electronic medical record, leading to missed documentation and follow-up. Staff interviews revealed breakdowns in communication and unclear protocols, resulting in neglect of the resident's care needs.
A resident with multiple serious diagnoses was not provided CPR when found unresponsive, despite having a full code order in the MAR. Staff did not initiate resuscitation, citing a DNR that was not documented in the facility records. Interviews revealed confusion and lack of proper documentation regarding code status, leading to a failure to provide basic life support as required.
Three residents received psychotropic or CNS stimulant medications without proper monitoring, documentation, or required stop dates. One resident was given an antipsychotic despite no documented behaviors or symptoms, another had a PRN antianxiety medication without a stop date while on hospice, and a third had PRN Adderall orders without end dates or administration. Facility staff were unaware of policy requirements for stop dates and did not consistently evaluate the clinical need for these medications.
Staff failed to follow infection control protocols during medication administration and did not consistently implement Enhanced Barrier Precautions for two residents requiring them. This included a nurse using her fingers to handle medications without hand hygiene, placing an insulin pen on bed linens, and staff not wearing gowns during IV administration and incontinent care, despite clear EBP signage and policies.
A resident with a tracheostomy and PEG tube was observed self-administering all medications without consistent assessment or documentation, contrary to facility policy. Nursing staff provided only intermittent oversight, and the DON was unaware of the full extent of self-administration, resulting in a deficiency related to safe medication management.
A resident with encephalopathy, dysphagia, and dementia did not receive physician-ordered adaptive feeding equipment during meals. Despite documentation in the care plan and orders, the dietary department was not informed, and the meal ticket did not reflect the need for adaptive utensils. Staff interviews confirmed a breakdown in communication, resulting in the resident not receiving the required equipment.
The facility did not ensure that Daily Staff Postings included the facility name, actual nurse hours in each cottage, or whether the nurse was an RN or LPN. Observations showed postings missing required details, and interviews revealed that nurses covered multiple cottages, making the posted information inaccurate. The DON confirmed the postings did not meet regulatory standards.
Two residents in the facility were observed with chair and bed alarms, which are considered restraints, without documentation of attempts to use less restrictive methods. Both residents had severe cognitive impairments and were at risk of falls, but the facility's policy prohibits using restraints for fall prevention. Staff interviews confirmed the use of alarms due to impulsivity and fall risk, but there was no documentation of monitoring or assessment, leading to a deficiency.
A facility failed to update the PASARR Level I for a resident after a new diagnosis of schizoaffective disorder was made. The resident, initially diagnosed with major depressive disorder and generalized anxiety disorder, was prescribed antipsychotic medication following the new diagnosis. Despite this, the PASARR screening was not revised, as confirmed by staff interviews and record reviews, indicating a lapse in communication and procedure adherence.
A facility failed to monitor a resident's antipsychotic medication for behaviors, side effects, and efficacy, as required by their policy. The resident, with diagnoses including Parkinson's disease and dementia, was prescribed Quetiapine Fumarate for Parkinson's psychosis. Despite the facility's policy mandating observation and documentation, no monitoring was recorded. Interviews confirmed the lack of documentation, highlighting a failure to ensure safe medication administration.
A resident with severe cognitive impairment and high fall risk sustained a laceration to her forehead after allegedly pulling a wooden chair onto herself. The chair, used by staff for feeding, was left next to the resident's bed, posing an unrecognized hazard. The incident underscores a failure to maintain a safe environment.
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. One resident was severely cognitively impaired, and the other was cognitively intact. Despite the facility's policy requiring immediate reporting of such incidents, the Director of Nursing did not report it, believing it was consensual based on the statements of the involved residents.
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. One resident was severely cognitively impaired, and the incident was not reported despite facility policy requiring immediate reporting of such incidents. The DON and ADON confirmed the incident was not reported, citing it as consensual.
Failure to Monitor and Administer Antihypertensive Medication for New Admission
Penalty
Summary
The facility failed to provide necessary care and services to a resident who was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Upon admission, the resident's blood pressure was recorded at 192/103, which exceeded the threshold for intervention as outlined in the facility's policy and the physician's order for as-needed antihypertensive medication. Despite this, documentation did not show that the ordered medication was administered following the elevated blood pressure reading. The resident's care plan indicated the need for antihypertensive medication and required staff to observe for side effects and promptly notify the physician if any were observed. However, there was a lack of communication and follow-through among staff regarding the resident's abnormal vital signs. The CNA who took the vital signs did not report the elevated blood pressure to the LPN, and the LPN was unaware of the abnormal reading. The resident was not entered into the electronic medical record system, which contributed to the lack of documentation and follow-up. The resident was later found unresponsive and pronounced deceased. Interviews with staff revealed confusion about reporting protocols and a lack of clarity regarding responsibilities for monitoring and responding to abnormal vital signs. The facility's failure to monitor and provide medications as ordered by the physician resulted in neglect of the resident's care needs, as evidenced by the lack of timely intervention for the hypertensive crisis.
Removal Plan
- Administrator notified the Medical Director of the Immediate Jeopardy.
- Director of Nursing and/or designee initiated education for all staff on Abuse/Neglect policies and procedures.
- All staff (including any agency assigned staff) that have not completed education will not be permitted to work until education is completed.
- Director of Nursing and/or designee initiated education to all nursing staff on procedure for follow up on abnormal vital signs.
- Director of Nursing and/or designee initiated education to all CNAs related to reporting abnormal vital signs.
- Director of Nursing and/or designee initiated an audit on all residents' Medication Administration Records (MARs) with anti-hypertensive and/or cardiovascular medications to ensure medications were given as ordered.
- 10 residents receiving cardiac medications will be audited weekly for 4 weeks and monthly for 2 months to ensure medications are given as ordered.
- Director of Nursing and/or designee initiated education with CNAs on facility policy and procedure for following checklist for taking resident vital signs.
- Director of Nursing and/or designee initiated education with all licensed nurses on what medications are available in Omnicell and how to pull medications from the Omnicell.
- Director of Nursing and/or designee initiated education for all licensed nurses on entering residents into PCC (PointClickCare) timely upon admission.
Failure to Initiate CPR Due to Inadequate Code Status Documentation
Penalty
Summary
The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident in accordance with physician orders and the resident’s code status. The resident was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Documentation revealed that the resident’s Medication Administration Record (MAR) indicated a full code status, but this was not reflected on the face sheet or care plan. When the resident was found unresponsive, staff did not initiate CPR, and the nurse documented that a Do Not Resuscitate (DNR) order was confirmed, despite the absence of such documentation in the medical record. Interviews with facility staff revealed confusion and inconsistency regarding the resident’s code status. The Director of Nursing (DON) and other staff members indicated reliance on information from the hospital and verbal statements from the resident’s daughter, but there was no documented discussion or signed DNR in the facility’s records. The nurse practitioner and other staff described challenges with entering code status into the electronic medical record and uncertainty about the process for confirming and documenting code status upon admission. The social services director also confirmed that there was no opportunity to speak with the resident or family about advance directives prior to the incident. The lack of clear documentation and communication regarding the resident’s code status led to the failure to provide basic life support as required by physician orders. The facility’s policies required that advance directives be respected and documented, but these procedures were not followed, resulting in the omission of CPR for a resident who was, according to available orders, a full code. This deficiency was determined by the survey team to constitute substandard quality of care and was cited under 42 CFR 483.24 – Quality of Life.
Removal Plan
- Administrator notified the Medical Director of Immediate Jeopardy.
- Social Service Director initiated an audit on Code Status for all new admissions.
- All code binders in all cottages audited to ensure they match orders in PCC.
- Social Service Director initiated an audit on Code Status for all other residents and audited code binders in all cottages to ensure they match orders in PCC.
- New admission's code status and code books will be audited.
- Social Service Director initiated an audit on Advanced Directive to determine if conversations with resident and/or responsible representative held at time of admissions for all new admissions.
- New admissions will be audited to ensure education offered on Advance Directives and code status honored.
- Education provided by the Assistant Regional Director of Clinical Services and Regional President of Operations to Administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director on conversations with resident and/or responsible representative for Advanced Directives upon admission.
- Education conducted as a review of facility policy and procedure in regard to Advanced Directives with resident and/or responsible representative upon admission.
- Education initiated by Director of Nursing and/or designee to all licensed nurses related to education resident and/or responsible representative on Advanced Directive and code status upon admission.
- All staff (including any agency-assigned staff) that have not completed education will not be permitted to work until education is completed.
- Director of Nursing and/or designee-initiated education for all nursing staff on Code Blue policy and procedures.
- Director of Nursing initiated an audit on Code Status accuracy and Advanced Directives on all resident Care Plans.
- Care plans will be audited to ensure code status is accurate.
Failure to Monitor and Document Psychotropic Medication Use and Stop Dates
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications and did not follow established protocols for medication monitoring and documentation. For one resident with a history of dementia, psychotic disturbance, and schizoaffective disorder, an antipsychotic medication (aripiprazole) was administered without documented evidence of behaviors or symptoms justifying its continued use. Multiple staff interviews confirmed the absence of hallucinations, delusions, or paranoia, and the resident herself denied current symptoms. Despite this, the medication remained active, and the interdisciplinary team had not documented a recent evaluation supporting its necessity. Another resident with Alzheimer's disease and agitation, who was on hospice care, had an active PRN order for lorazepam (an antianxiety medication) without a required stop date. The DON was unaware of the need for stop dates on hospice-prescribed medications. Additionally, a third resident with PTSD, major depressive disorder, and ADHD had two PRN orders for Adderall (a CNS stimulant) without end dates, and the medication had not been administered since being ordered. The DON did not recognize Adderall as a psychotropic medication and believed that unused orders would be discontinued after 30 days, but the orders remained active. Review of facility policy indicated that psychotropic medications should not be used unless clinically indicated and that PRN orders for such medications must have a documented rationale and duration, especially if extended beyond 14 days. The facility's failure to ensure adequate monitoring, documentation, and adherence to stop-date requirements for psychotropic and CNS stimulant medications resulted in deficiencies for three residents reviewed.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to administer medications and implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policies. During a medication pass, a registered nurse was observed using her fingers to obtain medications from bottles and medication cards without performing hand hygiene, and placed an insulin pen on a resident's bed linens before and after administration. The nurse acknowledged that these actions were improper and could lead to cross-contamination. The Director of Nursing confirmed that these practices should not have occurred. Additionally, staff did not consistently implement EBP for residents requiring such precautions. One resident with a history of sepsis due to MRSA received IV medication from a nurse who did not wear a gown, despite EBP signage indicating this requirement. Another resident with open wounds and on EBP was provided incontinent care by an LPN who did not wear a gown, stating she did not see the sign. There was confusion among staff regarding when gowns were required, with conflicting statements from the Staff Development Coordinator and the Infection Preventionist, despite clear signage outlining the need for gowns and gloves during personal care for residents on EBP.
Failure to Assess and Document Resident Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and document a resident's ability to self-administer medications, as required by its own policy. One resident, who had a history of left leg fracture, respiratory failure, a tracheostomy (without ventilator), and required a PEG tube for nutrition and medication administration, was observed self-administering all of his medications. Although the care plan indicated that the resident preferred and was capable of self-administering medications as determined by the interdisciplinary team, the facility's documentation and oversight were inconsistent. The Medication Administration Record (MAR) did not consistently indicate which doses were self-administered, and the Director of Nursing was unaware that the resident was self-administering all medications, being only aware of nebulizer treatments. Observations and interviews revealed that the resident was seen crushing and administering medications via PEG tube, with the nurse providing visual oversight only most of the time. The nurse confirmed that she documented medication administration in the MAR as with any other medication, regardless of whether it was self-administered. The facility's policy required an assessment of the resident's ability to self-administer medications and clear documentation in the MAR, but these steps were not consistently followed, leading to a deficiency in ensuring safe medication management for the resident.
Failure to Provide Physician-Ordered Adaptive Feeding Equipment
Penalty
Summary
The facility failed to provide physician-ordered adaptive feeding equipment for one resident, despite clear documentation in the resident's care plan and physician orders. The resident, who had diagnoses including encephalopathy, dysphagia, and dementia, was admitted with a need for adaptive utensils to aid in self-feeding. Observations showed that the resident's meal tray did not include the required adaptive equipment, and the meal ticket did not indicate the need for such equipment. Interviews with staff confirmed that the dietary department was not aware of the order for adaptive utensils, and the process for communicating such orders was not followed. Review of the resident's records revealed that the care plan and physician orders specified the use of adaptive utensils during all meals, and the nutritional assessment noted the resident's use of adaptive feeding equipment. However, the dietary manager confirmed that the meal ticket lacked this information, and the dietary staff did not have access to physician orders. The rehabilitation director stated that changes to diets or adaptive equipment were typically hand-delivered to dietary, but in this case, the order was missed and not communicated, resulting in the resident not receiving the necessary adaptive equipment.
Incomplete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Staff Posting included all required information, such as the facility name, the actual hours worked by nurses in each cottage, and whether the nurse on duty was an RN or LPN. Observations revealed that the staff posting in Dogwood Cottage did not display the facility name and lacked details about the nurse's credentials. The posting listed one nurse and one CNA for both day and night shifts, but did not specify if the nurse was an RN or LPN. Interviews with an LPN indicated that nurses were responsible for multiple cottages during their shifts, and the posted information did not accurately reflect their presence in each cottage. The facility also did not have a written policy for staff posting. The DON acknowledged that the current postings did not meet regulatory requirements.
Failure to Ensure Residents are Free from Restraints
Penalty
Summary
The facility failed to ensure that two residents, R93 and R107, were free from the use of physical restraints, as required by their policy. Both residents were observed seated in Broda chairs with chair alarms and had bed alarms in place. There was no documentation indicating that less restrictive methods were attempted before resorting to these alarms, which are considered restraints. The facility's policy mandates that restraints should only be used to treat medical symptoms and not for fall prevention, discipline, or staff convenience. Resident R93 was admitted with diagnoses including dementia, muscle weakness, and a history of falls. The resident was assessed as severely cognitively impaired and had physician orders for bed and chair alarms. Observations confirmed the use of these alarms, and interviews with staff revealed that the alarms were used due to the resident's impulsivity and fall history. However, there was no documentation of monitoring or assessment of the alarms, nor any evidence of attempts to use less restrictive interventions. Resident R107, also severely cognitively impaired, was admitted with conditions such as Parkinson's disease and dementia. The resident required substantial assistance for mobility and had orders for bed and chair alarms. Staff interviews indicated that the alarms were used due to the resident's impulsivity and fall risk. Similar to R93, there was no documentation of monitoring or assessment of the alarms, and the Director of Nursing confirmed that fall prevention was not a valid reason for their use. The lack of documentation and failure to attempt less restrictive methods contributed to the deficiency.
Failure to Update PASARR Level I for New Mental Health Diagnosis
Penalty
Summary
The facility failed to revise the Preadmission Screening and Resident Review (PASARR) Level I for a resident when a new diagnosis of schizoaffective disorder was made. The resident was initially admitted with diagnoses of major depressive disorder and generalized anxiety disorder, and later, a new diagnosis of schizoaffective disorder was added. Despite this significant change in the resident's mental health status, the facility did not update the PASARR Level I screening to reflect the new diagnosis, which is necessary to determine the need for specialized or rehabilitative services. The oversight was identified during a review of the resident's electronic medical record, which showed the addition of antipsychotic medication for the new diagnosis. Interviews with facility staff, including the MDS Coordinator and the Social Services Director, revealed a lack of communication and follow-through in updating the PASARR screening. The Director of Nursing also confirmed the expectation for a new PASARR Level I to be completed with such a diagnosis change. The facility's training materials indicated that a new PASARR Level I should be conducted for serious mental illness diagnoses, but this was not adhered to in this case.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's antipsychotic medication, leading to a deficiency in the safe administration and dosing of the medication. The resident, identified as R93, was admitted with diagnoses including anxiety disorder, Parkinson's disease with dyskinesia, and dementia. The resident had a physician's order for Quetiapine Fumarate, an antipsychotic medication, to be administered at bedtime for Parkinson's psychosis. However, the facility did not monitor the resident for behaviors, side effects, or the efficacy of the medication as required by their policy. The facility's policy on antipsychotic medication use mandates that staff observe, document, and report the effectiveness of interventions, including antipsychotic medications, and monitor for side effects. Despite this, a review of the resident's medication administration records revealed no documentation of such monitoring. Interviews with the nursing staff and the Director of Nursing confirmed the absence of necessary documentation and monitoring, which should have been flagged during chart audits. This oversight indicates a failure to adhere to the facility's policy, compromising the safe administration of the antipsychotic medication.
Resident Injury Due to Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, hazard-free environment for a resident, resulting in an accident. The resident, who was severely cognitively impaired and wheelchair-bound, was dependent on staff for all activities of daily living. The resident had a history of falls and was assessed as a high fall risk. Despite these known risks, a wooden chair was left next to the resident's bed, which the resident allegedly pulled onto herself, causing a laceration to her forehead that required sutures. The chair was used by staff to feed the resident while she was in bed, but it was not recognized as a potential hazard. On the day of the incident, the resident was found with blood on her face, clothing, and sheets. Staff interviews revealed that the chair was used for feeding the resident, and there was a small amount of blood on the chair's arm. The Director of Nursing conducted an investigation and concluded that the chair was the cause of the injury. The incident highlights a failure to ensure the resident's environment was free from accident hazards, despite the resident's high fall risk and cognitive impairment.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. According to the facility's policy, any resident-to-resident altercations involving sexual contact must be reported immediately, but no later than two hours, especially when one resident's capacity to consent is unknown. Resident 1 (R1) was severely cognitively impaired with a BIMS score of 6 out of 15, while Resident 2 (R2) was cognitively intact with a BIMS score of 13 out of 15. On the night of the incident, a CNA found both residents disrobed and standing beside the bed in R1's room. R1 was upset and crying, stating she did not mean to do it. R2 claimed that R1 had invited him into her room. Despite the incident, the Director of Nursing (DON) did not report it to the state agency, believing it was consensual based on R1's statements. Interviews with various staff members, including a CNA, RN, NP, ADON, and DON, revealed that R1 initially denied the allegation but later admitted to initiating the contact and expressed that R2 did not do anything wrong. R2 was sent to the ER after becoming upset and non-compliant when told he could not return to R1's room. The police were called but did not file a report because R1 expressed that the incident was consensual. Despite these findings, the facility did not follow its policy to report the incident to the state agency, leading to a deficiency in handling and reporting suspected abuse or neglect.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. According to the facility's policy, such incidents should be reported immediately but no later than two hours. The incident involved Resident 1, who was severely cognitively impaired with a BIMS score of 6, and Resident 2, who was cognitively intact with a BIMS score of 13. The incident was discovered by a Registered Nurse who found both residents disrobed from the waist down. Resident 2 claimed that Resident 1 had invited him into the room, and Resident 1 confirmed this, stating that Resident 2 did not do anything wrong. Despite this, the facility's policy mandates reporting any sexual activity where one resident's capacity to consent is unknown, which was the case with Resident 1 due to her severe cognitive impairment. The Assistant Director of Nursing and the Director of Nursing both confirmed that the incident was not reported to the state agency. The ADON mentioned that the police were called but did not file a report because Resident 1 expressed that the interaction was consensual. The DON stated that the incident was not reported to the state agency because it was deemed consensual. This failure to report the incident constitutes a violation of the facility's policy and regulatory requirements for reporting allegations of abuse.
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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