Calhoun Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Matthews, South Carolina.
- Location
- 601 Dantzler Street, Saint Matthews, South Carolina 29135
- CMS Provider Number
- 425170
- Inspections on file
- 28
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Calhoun Convalescent Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, wandering behavior, and documented elopement risk eloped after staff failed to adequately respond to an exit-door alarm and did not promptly recognize the resident was missing. The resident, who required close supervision and was on 30-minute checks for wandering, was last seen ambulating in the facility before a dining room/fire exit alarm sounded; dietary staff briefly checked, saw no one, silenced the alarm, and returned to work without initiating a facility-wide missing-resident response. Later, when the resident did not appear for dinner, staff began searching and learned from a staff member driving home that someone resembling the resident was seen near a nearby store. Police, responding to a report of a suspicious person with a hospital bracelet, found the resident disoriented at a nearby intersection and arranged EMS transport to a hospital. Interviews showed that some CNAs lacked elopement training, one CNA was newly assigned to 1:1 care, and leadership acknowledged uncertainty about how long the alarm had been sounding and how the resident exited, supporting the finding of inadequate supervision and failure to prevent elopement.
The facility failed to follow its abuse reporting policy by not reporting allegations of sexual abuse involving three cognitively impaired residents to the State Agency within the required 2-hour timeframe. One resident was observed by a CNA with her hands inside another resident's brief, and it was also alleged that two residents had sexual intercourse when one was found in the other's bed. These allegations were known to multiple staff, including department heads and LPNs, and were discussed in a staff meeting, but were not documented in the residents' progress notes and were not promptly reported by staff to the Abuse Coordinator or by the Abuse Coordinator to the State Agency.
A resident with dementia, severe cognitive impairment, history of falls, and multiple comorbidities had a care plan identifying fall risk and specifying interventions such as a bedside fall mat, environmental safety measures, monitoring during ambulation, and reminders to call for assistance. Despite a documented history of falls and dependence on a Hoyer lift with two-person assist, observations showed the resident in bed, periodically pulling up on bedrails, with the bed in low position but without the ordered fall mat in place. The DON reported that MDS and care plans were not updated due to staffing issues, there was no current MDS nurse, and the resident’s fall and related interventions were not documented in the care plan.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a Wander guard. The door alarm system was triggered, but staff response was delayed, leading to the resident being found outside after falling and hitting her head. The facility's elopement policy was not effectively implemented.
Failure to Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had dementia with severe cognitive impairment, a BIMS score of 7/15, generalized muscle weakness, unsteadiness on feet, and abnormal gait and mobility. The admission MDS and care plan identified the resident as at risk for falls and elopement, with documented wandering throughout the facility and a recent elopement. An elopement risk observation completed shortly before the incident documented that the resident did not have safe decision-making capabilities. Nursing staff reported that the resident remained ambulatory with good strength and endurance, had impaired judgment and poor safety awareness, and required close supervision due to ongoing exit-seeking behaviors. On the day of the incident, staff last observed the resident in a safe environment ambulating in the facility between approximately 5:30 PM and 5:40 PM, which was described as baseline behavior. Around this same time frame, the alarm on a dining room/fire exit door near the dietary department sounded. Dietary staff responded, visually checked the area, reported not seeing anyone, re-engaged or disarmed the alarm, and returned to the kitchen. Multiple staff later acknowledged that it was difficult to hear the alarm in the kitchen and that they were unable to determine how long the alarm had been sounding before it was noticed. The facility’s elopement policy required immediate notification of all employees and a prompt, thorough search process when a resident was considered missing, but there is no indication that a facility-wide code or missing resident procedure was initiated at the time the door alarm sounded. Subsequently, between approximately 5:50 PM and 6:05 PM, the resident’s CNA noticed the resident was not in the room to receive a dinner tray and began looking for the resident, prompting a census head count. Staff were unable to locate the resident in the building, and a search was initiated. Around 6:08 PM to 6:39 PM, an employee leaving work by car believed they saw the resident near a nearby Dollar General store and called the facility. A nurse drove to the store but did not find the resident. During this period, the local police were notified by Dollar General about a suspicious person with a hospital bracelet. Police located the resident at a nearby intersection; the police report described the resident as delirious, disoriented, and unable to provide coherent responses. EMS was requested, and the resident was transported to a hospital emergency department. The facility later confirmed that the resident had eloped from the building and was found with a wander guard still in place, and staff, including the administrator and DON, were unable to state exactly how the resident exited the building, though they believed it may have been through the dining room door whose alarm had sounded earlier. Interviews with staff revealed additional gaps related to supervision and elopement procedures. One CNA assigned to 1:1 care for the resident stated it was her first day in that role and could not confirm how long the resident had been on 1:1 care. Another CNA, who had recently completed orientation, reported not receiving any in-service training related to elopements and stated that the survey interview was the first time she heard about the resident’s exit from the building. The LPN on duty reported that the resident had been on 30-minute checks due to wandering, last saw the resident around 5:25 PM–5:30 PM, and assumed the resident was doing usual laps in the facility. The DON and administrator both acknowledged that staff could not determine how long the door alarm had been sounding before it was heard and that staff responded by looking outside, not seeing anything, and shutting off the alarm. These actions and inactions, in the context of a known high-risk, cognitively impaired, exit-seeking resident, led to a successful elopement and formed the basis of the cited deficiency under 42 CFR 483.25 for failure to keep the environment free of accident hazards and provide adequate supervision.
Removal Plan
- Evaluate resident at emergency room; confirm no injuries.
- Initiate and continue 1:1 supervision for the resident.
- Assess each exit door to validate doors are working properly.
- Update the resident’s elopement risk assessment to reflect current status.
- Update the resident’s care plan and resident profile.
- Complete an elopement drill.
- Administrator will notify the charge nurse, Director of Nursing, and Social Service designee that a resident is missing as part of drill procedure.
- Director of Nursing/designee will announce Code [NAME] to signal the elopement drill procedure.
- Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds; complete the entire search process within 30 minutes.
- If search fails to locate resident within allotted time, Administrator/designee will place a mock telephone call to appropriate community agencies, resident's legal representative, and attending physician; staff will provide mock police with physical identifying information.
- Continue the search if resident not located, including having staff search surrounding streets by car for a 2 mile radius.
- When the volunteer resident is located, the charge nurse will complete a head-to-toe assessment.
- Social Services designee will assess the resident for emotional distress.
- Director of Nursing will notify appropriate community agencies, attending physician, and resident's legal representative.
- Facility Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences.
- When missing resident is found, make an announcement: Code [NAME] all clear.
- Update elopement risk assessments for all residents.
- Place residents identified as elopement risk in the elopement binder and update their care plans and profiles.
- Reeducate facility staff on the elopement policy and Abuse, Neglect & Misappropriation policy.
- Provide education to any staff not receiving this education prior to their next scheduled shift.
- Review new admission elopement risk assessments in Clinical Morning Meeting to validate accuracy and interventions if indicated.
- Review quarterly elopement risk assessments to validate accuracy and interventions if indicated.
- Maintenance Director/designee will inspect facility exit doors to validate doors are functioning properly.
- Administrator will round with the Maintenance Director validating doors are functioning properly.
- Hold an Ad Hoc QACPI.
- Notify the Medical Director of the incident and plan.
- Present results of audits in the QAPI Committee meeting for review and recommendations.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to follow its abuse, neglect, exploitation, or mistreatment policy requiring that all alleged violations concerning abuse be reported immediately and verbally to the Facility Abuse Coordinator, the Administrator, and the State Survey and Certification Agency. The policy also states that employees have the right to report allegations directly to the state agency. Despite this, allegations of sexual abuse involving three residents were not reported to the State Agency within the required 2-hour timeframe. The abuse allegations were discussed in a morning staff meeting on 02/06/2026, and some staff reported learning of the allegations as early as 02/04/2026 and 02/05/2026, but there was no timely notification to the State Agency as required. The residents involved all had significant cognitive impairments. One resident had diagnoses including cognitive communication deficit and dementia, with an admission BIMS score of 2/15 indicating severe cognitive deficits. Another resident had diagnoses including alcohol dependence with alcohol-induced persisting dementia, PTSD, anxiety disorder, major depressive disorder, and schizophrenia, and a Quarterly MDS documented that a BIMS was not conducted because the resident could not understand and was not understood. The third resident had diagnoses including dementia, TIA, cerebral infarction, convulsions, adult failure to thrive, and cocaine use, with a Quarterly MDS BIMS score of 6/15 indicating severe cognitive deficits. Allegations included one resident being observed by a CNA with her hands in the brief of another resident, and a separate allegation that two residents had sexual intercourse when one was found in the bed of the other. Progress notes for all three residents contained no documentation of alleged abuse, and although multiple staff members, including department heads and LPNs, were aware of the allegations and the allegations were reported to a nurse when they occurred, staff did not report them to the Abuse Coordinator, and the Abuse Coordinator did not report them to the State Agency.
Failure to Implement Care Plan Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions related to fall prevention for one resident identified as being at risk for falls. Facility policy on Fall Management, revised 05/05/23, requires that residents at risk for falls be identified, that care be planned, and that interventions be implemented and reflected on the care plan, with individualized interventions reassessed and revised as needed. The resident had diagnoses including dementia, history of falling, diabetes mellitus, hypokalemia, chronic kidney disease, and urinary tract infection, and a Quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. The same MDS documented that the resident required maximum assistance for bed mobility, was dependent for toilet transfers, and had no falls since admission or prior assessment. The resident’s care plan, initiated 05/29/2024, identified impaired cognitive function and risk for falls related to dementia, decreased mobility, history of falls, impaired vision, and impaired cognition, and included interventions such as maintaining a safe environment with even, clutter-free floors, nursing monitoring during ambulation in the hall, encouraging the resident to wait for assistance before ambulating, use of a fall mat at bedside, reminders to call for assistance with the call bell prior to transfers and ambulation, and staff education. A Fall Incident Report dated 10/19/2025 documented that the resident had a history of falling, was bed bound, required a Hoyer lift and two-person assist for transfers, and had a last fall on 10/24/2024. On two separate observations on 02/11/2026, the resident was seen in bed asleep with the bed in the lowest position, periodically pulling herself up using top bedrails, and no fall mats were in place despite the care plan intervention. In an interview, the DON stated that the care plan and MDS were not updated, that there had been only one MDS nurse who was behind, that there was currently no MDS nurse on staff, and that unit managers were trying to update MDS and care plans daily; the DON also acknowledged that the fall was not documented in the care plan and that interventions should have been put in place based on submitted statements.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision to prevent a resident's elopement, which resulted in Immediate Jeopardy. The resident, who was severely cognitively impaired with a BIMS score of 1 out of 15, had a history of wandering and was at risk of elopement. Despite having a Wander guard in place, the resident managed to leave the facility unsupervised. On the evening of the incident, the door alarm system was triggered, but the response was delayed due to confusion about which door was alarming. The resident was found outside in the parking lot, having fallen and hit her head. Interviews with staff revealed that the alarm system was functioning, but the response was not immediate, leading to the resident's successful elopement. The resident's medical history included vascular dementia, neurocognitive disorder with Lewy bodies, and other conditions requiring supervision. The facility's policy on elopement was not effectively implemented, as evidenced by the resident's ability to leave the premises and sustain an injury.
Removal Plan
- Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution.
- Elopement risk evaluation repeated.
- Resident had Wandergard in place and properly functioning at time of incident.
- MD/RP notified.
- Administrator and CSD notified of incident.
- Residents at risk of elopement have the potential to be affected.
- Elopement risk evaluations done on current residents in facility reviewed by nursing managers for accuracy.
- Residents identified at risk will be reviewed for appropriate interventions.
- All doors check for auditory alarm; found to be in working order.
- Educate facility staff the expectation that if a door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents.
- If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management.
- Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified.
- Staff will be reeducated on appropriate response to alarms.
- Any member of target audience not receiving this will receive prior to next scheduled shift.
- New admissions will be reviewed in morning meeting daily as part of the clinical morning meeting process.
- Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated.
- Quarterly assessments will be reviewed as part of the MDS/Care planning process.
- The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy.
- The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months.
- The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly.
- The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance.
- Ad hoc QAPI held.
- Medical Director was notified of the incident and plan for improvement.
- This process will be reviewed in QAPI for a minimum of 3 months.
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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