Carlyle Senior Care Of Florence
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, South Carolina.
- Location
- 133 West Clarke Road, Florence, South Carolina 29501
- CMS Provider Number
- 425163
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Carlyle Senior Care Of Florence during CMS and state inspections, most recent first.
Late quarterly MDS assessments were found for multiple residents, with 19 of 19 quarterly reviews completed beyond the 92-day requirement. Record review showed several assessments were completed 124 to 144 days after the prior quarterly review or ARD, and one assessment had no completion date. The DON said the ADON signs off on MDS assessments behind the LPN AA and did not know the due timeframes, while the RNC acknowledged several late assessments.
Failure to Address Ongoing Low Water Temperatures: The facility did not implement an effective QAPI/PIP to address persistent low water temperatures and plumbing issues. QAPI minutes showed no PIP related to the problem, while logs and observations found tepid water in resident rooms, shower areas, and other care areas, with temperatures as low as 68 degrees. Staff, including CNAs, an LPN, and maintenance personnel, reported the issue had been ongoing for months, and residents stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water.
Inconsistent hot water temperatures in resident care areas. The facility had multiple areas with only cold or tepid water, including resident room bathrooms, a shower room, and staff/visitor bathrooms. A Maintenance Director said water temperatures were checked weekly, but staff and residents reported ongoing problems for months, with some residents routinely cleaned with cold to tepid water and staff sometimes needing to use water from other rooms for bathing and handwashing.
A facility failed to document and resolve resident grievances about water temperatures. Several residents reported no hot water in their room bathrooms and said they were bathed with cold to tepid water, while another resident said the water in his room was never warm. Surveyors also observed low water temperatures in multiple rooms and a shower room. The DON stated the concerns were treated as situational reports rather than a formal grievance, and no resident meeting or grievance resolution occurred.
Late MDS Assessments: The facility failed to complete Annual MDS assessments within the required timeframe for eight residents and failed to complete admission MDS assessments within 14 days for two residents. Record review showed multiple assessments were completed well past the ARD or admission date, and staff interviews indicated confusion about MDS due dates and submission timeframes.
A resident with multiple diagnoses, including DM, COPD, respiratory failure, pressure and venous/arterial ulcers, and hospice/palliative care, had a significant change MDS completed far beyond the required timeframe. The record showed the significant change date was identified well before the assessment completion, and CAAs were completed at the same time as the late MDS. An LPN stated assessments are due within 14 days, while the DON said she did not know the assessment or submission timeframes.
The facility did not implement a comprehensive, data-driven QAPI program as required, particularly in the area of abuse prevention. The only documented performance improvement project was a brief, inadequately documented effort by the Administrator, lacking analysis, supporting documentation, or sub-committee involvement. Multiple abuse complaints were substantiated during the survey, and the facility's approach did not meet its own policy standards.
The facility did not consistently monitor or evaluate antibiotic use, as antibiotics were started for several residents without obtaining appropriate cultures or laboratory confirmation. In multiple cases, antibiotics were prescribed after hospital visits or for wound care without following the facility's policy for antibiotic stewardship, and staff interviews confirmed that required cultures were not always obtained before starting treatment.
A resident who had been certified by two physicians as unable to make healthcare decisions was given information about psychotropic medication and signed the informed consent form, rather than the resident's representative. The DON relied on the resident's BIMS score and was unaware of the incapacity certification, resulting in the failure to properly inform and obtain consent from the appropriate party.
A medication cart was left unattended in a hallway with its computer screen displaying resident names, allowing multiple individuals to pass by and potentially view protected health information (PHI). An LPN admitted to leaving the screen open and not knowing how to lock it, while the DON confirmed that staff are required to keep such information out of sight and secure.
The facility did not conduct comprehensive investigations into incidents of resident-to-resident abuse, failing to interview all involved parties and witnesses, and omitting key documentation. In two separate altercations involving residents with cognitive impairments, the facility's investigations lacked statements from all involved individuals and did not identify or interview staff witnesses, contrary to policy requirements.
Multiple incidents occurred where residents were not protected from physical and verbal abuse, including a cognitively impaired resident striking another, a staff member verbally abusing a resident with threats and profanity, and two residents with dementia engaging in a physical altercation after one wandered into the other's room. Staff did not always intervene promptly or complete required assessments in a timely manner, resulting in lapses in abuse prevention and resident care.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within 92 days of the most recent prior quarterly review or comprehensive assessment for 14 of 16 residents reviewed, with 19 of 19 quarterly assessments found to be late. The report states that the facility policy required quarterly assessments to be completed using an ARD no greater than 92 days from the most recent prior quarterly or comprehensive assessment, but multiple resident records showed assessments completed well beyond that timeframe. Examples included quarterly assessments for residents with ARDs or prior quarterly review dates that were 124, 129, 132, 135, 136, 138, 139, 143, and 144 days apart from completion dates, and one quarterly assessment had no completion date as of the survey date. The records reviewed identified late quarterly assessments for residents including R17, R7, R27, R33, R42, R48, R52, R55, R60, R63, R73, R74, R9, and R8. The DON stated that the ADON signs off on MDS assessments behind the LPN AA and said she did not know the assessment or submission timeframes for due dates. The RNC stated that assessments are due by the 92nd day and submissions are due after that, and acknowledged several late assessments when shown the list of 16 residents' assessments.
Failure to Address Ongoing Low Water Temperatures
Penalty
Summary
The facility failed to implement an effective Performance Improvement Plan to address ongoing low water temperatures throughout the building. Review of the facility QAPI document and QAPI meeting minutes from 2/2025 through 2/2026 showed no indication of a Performance Improvement Plan related to plumbing problems or water temperatures. The Water Temperature Log for 2026 documented temperatures below 100 degrees in multiple weeks, including the whirlpool and resident rooms. During observations on 3/24/26, 3/25/26, and 3/26/26, surveyors found tepid water in resident care areas, including temperatures as low as 68 degrees in the west hall shower room and temperatures in resident rooms ranging from 70 to 98.5 degrees. Interviews confirmed the water issue had been ongoing and widely known among staff and residents. The Director of Maintenance stated water temperatures were checked weekly and adjusted as needed, but he was not sure of a minimum hot water temperature. Maintenance staff reported checking hot water heaters when temperatures were below 100 degrees. CNAs and an LPN reported inconsistent water in resident rooms and shower areas, with staff sometimes needing to use water from other rooms to bathe residents or wash hands. Four cognitively intact residents stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water. The Administrator stated he was unaware of the low water temperatures and the nonworking hot water faucet in the center employee/visitor restroom, and the Administrator, DON, and Senior Nurse Consultant stated they had not put a PIP in place to address the low water temperatures.
Inconsistent hot water temperatures in resident care areas
Penalty
Summary
The facility failed to ensure comfortable water temperatures were maintained throughout resident care areas. Review of facility policies showed the facility was expected to maintain appropriate water temperatures in resident care areas and to report abnormal findings such as water that was too cold or hot. During observations, the center hall visitor/employee bathroom had only cold water from the faucet, and the west hall visitor/employee bathroom had only cold water flowing from both the hot and cold faucets after the water was allowed to run for five minutes. Additional observations in resident rooms and the west hall shower room showed water temperatures ranging from 98.5 degrees to 68 degrees, with several readings below 100 degrees and some as low as 70 degrees and 68 degrees. Interviews confirmed the issue had been ongoing for months. The Director of Maintenance stated water temperatures were checked weekly and adjusted as needed, but he was not sure of a minimum hot water temperature. A Maintenance Assistant stated that when water temperatures were lower than 100 degrees, he checked the hot water heaters to ensure the temperature at the heater was 120 degrees. CNAs and an LPN reported that some resident rooms and the shower room had only cold or tepid water, and staff sometimes had to go to other rooms to obtain hot water for bathing or handwashing. Four cognitively intact residents who participated in Resident Council stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water; one resident also reported the shower room water was often too cold. The Administrator, DON, and Senior Nurse Consultant stated they were not aware of complaints about hot water not being available in various parts of the facility.
Failure to Document and Resolve Resident Grievances About Water Temperature
Penalty
Summary
The facility failed to ensure resident grievances were documented and resolved regarding uncomfortable water temperatures. During a group interview, four cognitively intact residents stated there was no hot water in the bathrooms in their rooms and that they were routinely cleaned with cold to tepid water; one resident also stated the shower room water was often too cold. The residents said they had discussed the issue with the former Activities Director, but the current AD’s resident council notes from December 2025 through March 2026 contained no documented concerns about water temperature, and the grievance logs from March 2025 through March 2026 contained no grievances related to water temperatures. One resident also reported that the water in his room was never warm and that staff sometimes bathed him in cool water or obtained water from another room. During observation, water temperatures in several resident rooms and the west hall shower room were measured at 98.5 degrees, 97 degrees, 90 degrees, and 90 degrees. The Maintenance Assistant stated that when water temperatures were lower than 100 degrees, he checked the hot water heaters to confirm the temperature at the heater was 120 degrees. The DON stated the residents’ concerns had been reported situationally rather than as a formal grievance, so no grievance was addressed and she had not met with the residents regarding a resolution. The Administrator, DON, and Senior Nurse Consultant later stated they were not aware of complaints about hot water not being available in various parts of the facility, and they said the Maintenance Director did not notify them of abnormal temperature findings during weekly checks.
Late MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive Annual MDS assessments were completed within 366 days of the ARD for eight of eight residents reviewed who required an Annual MDS assessment. The record review showed that the Annual MDS assessments for R7, R17, R27, R33, R52, R60, R63, and R73 were completed after the required timeframe, with completion dates ranging from 21 to 52 days past the ARD. The facility policy titled MDS 3.0 Completion stated that an Annual Assessment is a comprehensive assessment completed using an ARD no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The facility also failed to ensure comprehensive admission MDS assessments were completed within 14 days of admission for two of six residents reviewed for admission MDS assessment. R55's admission MDS was completed 57 days after admission, and R81's admission MDS was completed 18 days after admission. During interview, an LPN stated that assessments are due within 14 days of the due date and are required to be submitted within 14 days of completion. The DON stated that the ADON signs off on MDS assessments behind the LPN and that she did not know the assessment or submission timeframes for due dates.
Delayed Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days of identifying a significant change in status for one resident. The resident had diagnoses including diabetes mellitus requiring insulin, hyperlipidemia, arthritis, anxiety disorder, depression, COPD and respiratory failure, chronic pain syndrome, weakness, peripheral vascular disease, psychophysiologic insomnia, pressure and venous/arterial ulcers, and hospice/palliative care. The resident’s MDS showed a significant change date of 10/30/25, but the assessment was not completed until 12/15/25, which was 46 days after the significant change date. The record also showed that 10 CAAs were completed on 12/15/25 for the significant change MDS, including cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, behavioral symptoms, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain. During interview, an LPN stated that assessments are due within 14 days of the due date and must be submitted within 14 days of completion. The DON stated that the ADON signs off on MDS assessments behind the LPN and said she did not know the assessment or submission timeframes for due dates.
Failure to Implement Effective QAPI Program for Abuse Prevention
Penalty
Summary
The facility failed to develop and implement an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that addresses all aspects of care, quality of life, and resident safety, specifically related to abuse prevention. The facility's QAPI policy required systematic investigations and analysis of underlying causes or contributing factors for problems affecting facility-wide processes. However, review of the facility's performance improvement projects (PIPs) over the past year revealed that the only documented PIP on abuse prevention was a single-page document completed in two days by the Administrator, with no supporting documentation, analysis, or evidence of a sub-committee or summary of activities. The PIP used an outdated federal regulation reference and set a goal of zero abuse without further detail or analysis. During interviews, the Administrator, DON, and Infection Preventionist confirmed the lack of comprehensive documentation and analysis for the PIP. The survey team substantiated three abuse complaints during their visit, and noted that several abuse complaints had been investigated by the State Agency three weeks prior. The PIP did not include a summary, identification of the issue to QAPI, involvement of a sub-committee, or an analysis of the process, indicating a lack of systematic investigation and data-driven approach as required by the facility's own policy.
Failure to Monitor and Evaluate Antibiotic Usage
Penalty
Summary
The facility failed to monitor and evaluate antibiotic usage for four out of five residents reviewed for antibiotic use. According to the facility's Antibiotic Stewardship Program policy, antibiotic orders should be reviewed for appropriateness, and random audits should be performed to verify completeness and appropriateness. However, in multiple cases, antibiotics were started without appropriate cultures being obtained. One resident was sent to the emergency room for an indwelling urinary catheter, received an antibiotic without a culture being done, and the Infection Preventionist did not question the order. Another resident returned from the ER on an antibiotic for urinary retention without a urine analysis or culture being completed. A third resident was sent to the ER for a change in condition, received a urine analysis but no culture, and was started on an antibiotic. A fourth resident with a Stage IV pressure ulcer was started on doxycycline for 14 days after a wound odor was noted, but no wound culture was obtained prior to starting the antibiotic. Interviews with staff confirmed that cultures were not consistently obtained before starting antibiotics, and that the Infection Preventionist and wound doctor were aware that cultures should have been completed but were not. The Infection Preventionist acknowledged the need to obtain cultures from the hospital or to call for them if not provided, and the wound doctor admitted that a culture should always be completed before prescribing antibiotics. The administrator stated that the expectation is to follow CMS guidelines for antibiotic stewardship.
Failure to Obtain Proper Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's representative was informed of the risks and benefits associated with the use of psychotropic medications. The resident in question was admitted with a diagnosis that included strange and inexplicable behavior. Although the resident's Brief Interview for Mental Status (BIMS) score indicated cognitive intactness, two physicians had certified that the resident was unable to make healthcare decisions for himself. Despite this certification, the informed consent for psychoactive medication use was signed by the resident rather than the resident's representative. The Director of Nursing (DON) completed the consent process by discussing the medication with the resident and obtaining his signature, relying solely on the BIMS score and not reviewing the certification of incapacity. The DON later acknowledged being unaware of the resident's incapacity status and agreed that the resident's representative should have been the one to receive information and provide consent. This oversight resulted in the resident, who had been deemed incapable of making healthcare decisions, being the sole recipient of information regarding the psychotropic medication and the one to sign the consent form.
Failure to Secure Electronic Medical Records Exposes PHI
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as required by its HIPAA Security Measures policy. During an observation, a medication cart was left unattended in the hallway with the computer screen on, displaying the names of six residents. Multiple residents and staff walked past the cart and could view the screen before the LPN returned. The LPN stated she typically leaves the screen open with residents' names visible and was unaware of how to lock the screen, acknowledging that protected health information (PHI) could be immediately accessed by clicking on a resident's name. The Director of Nursing confirmed that staff are expected to keep computer records out of sight and lock screens when not present, and that all documentation containing PHI should be secured.
Failure to Thoroughly Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse, as required by its own policy and regulatory standards. In one incident, two residents with cognitive impairments were involved in a physical altercation in a TV room, but the investigation did not document what occurred, who the aggressor was, or include interviews with all involved parties. Specifically, there was no interview with the cognitively intact resident involved, no identification or interview of the staff member who witnessed the incident, and no interviews with other residents who may have had knowledge of the event. In another incident, a resident with Alzheimer's disease who wandered into another resident's room was involved in a physical altercation with two other residents, one of whom had dementia and the other was cognitively intact. The facility's investigative documents did not include interviews with other residents who may have witnessed the event. The investigation relied only on statements from the directly involved residents, and there was no written statement regarding the inability to interview the resident with a low BIMS score due to cognitive impairment. Interviews with the facility's Administrator confirmed that the investigations did not include all required interviews and documentation. The Administrator acknowledged that staff should have interviewed all involved residents and witnesses, and that the investigation was incomplete in identifying and interviewing all relevant parties. The lack of thorough investigation had the potential to affect other residents at risk for abuse.
Failure to Prevent and Respond to Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as well as neglect, involving both resident-to-resident and staff-to-resident incidents. In one case, a resident with severe cognitive impairment and a history of disruptive behaviors physically struck another cognitively intact resident in a common area. Staff and witnesses confirmed the altercation, and the incident was substantiated by the facility administrator. The care plan for the aggressor included interventions to de-escalate agitation, but the incident still occurred, indicating a lapse in prevention measures. Another incident involved a staff member verbally abusing a cognitively intact resident by accusing him of theft, using profane language, and threatening physical harm. Multiple staff and the resident confirmed the verbal abuse, and the staff member was immediately suspended and did not return to the facility. The facility's investigation corroborated the resident's account and the inappropriate conduct by the staff member. Additionally, there was a physical altercation between two residents, both with cognitive impairments, after one resident wandered into another's room. The altercation resulted in minor injuries, and staff intervened to separate the residents. However, the required skin assessment for one of the residents was not completed until the following day, indicating a delay in post-incident care. These events demonstrate failures in supervision, timely assessment, and adherence to abuse prevention policies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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