Cheraw Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheraw, South Carolina.
- Location
- 400 Moffat Road, Cheraw, South Carolina 29520
- CMS Provider Number
- 425005
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Cheraw Healthcare during CMS and state inspections, most recent first.
Missing Annual CNA Competency Evaluations: The facility failed to ensure and document annual competency evaluations for 5 of 5 CNAs reviewed. Facility policy required competency evaluations during orientation, annually, and as needed, but personnel records showed no annual evaluations within the required timeframe. The HR Director and Administrator both confirmed the evaluations had not been completed as required.
Failure to provide routine hair and nail care: A resident with severe cognitive deficits, stroke history, and an ADL self-care deficit was observed over multiple days with dirty fingernails and hair that was dirty and matted. The care plan called for assistance with bathing and personal hygiene, but the resident remained unclean until the concern was brought to the attention of the assigned LPN.
Failure to attempt a GDR for a resident with Alzheimer's dementia who was receiving Quetiapine 200 mg HS. The resident had severe cognitive impairment, low body weight, weight loss, and multiple falls, and the MRR recommended considering a dose reduction. The physician chose to maintain the dose, but the record lacked resident-specific clinical rationale for not reducing the antipsychotic.
Expired Aspirin was found in a medication cart with in-date medications in 1 of 4 carts reviewed. The facility policy assigned nursing staff responsibility for maintaining medication storage and preparation areas, and an LPN confirmed the expired bottle during observation and removed it from the cart.
Out-of-range nourishment refrigerator temperatures were observed in the North Unit Hall-100 nourishment room. The refrigerator held resident supplements, juices, and personal food items, and the temperature gauge read 46 degrees F, above the facility’s required 41 degrees F limit. Records showed repeated elevated readings over several days, and interviews with the KM, Maintenance Director, and Administrator confirmed the issue had been reported and that the refrigerator and thermometer had been replaced or changed, but temperatures remained out of range.
A resident with severe cognitive impairment was mistakenly given medications intended for her roommate by an RN, leading to symptoms such as hypotension and diaphoresis, and requiring hospitalization for drug overdose. The incident was compounded by a lack of documented vital sign monitoring in the medical record, and was cited as a significant medication error under pharmacy services.
Expired medications and biologicals were found in two medication storage rooms. In the South Unit, an LPN verified and removed an expired BD Vacutainer Red Top. In the North Unit, the DON confirmed and removed an expired BD Vacutainer Gel and Lithium Heparin Top, expired Covidien Filac Probe Covers, and expired Covidien Kangaroo Epump Sets. These findings indicate a failure to follow the facility's policy on proper storage.
The facility failed to ensure accurate documentation of Advance Directives for several residents, leading to discrepancies between hard charts and EMRs. One resident's DNR order was missing from the EMR, while another had conflicting code status information. Staff interviews revealed issues with the transition to a new electronic system, contributing to the documentation gaps.
A facility failed to complete a restraint assessment for a resident using a trunk restraint on a wheelchair. The resident, who is severely cognitively impaired, was observed with a lap n lock padded lap desk, but no documentation of an assessment or consent was found in their records. Staff confirmed the absence of necessary documentation, and a late entry assessment and unsigned consent form were later provided. The resident's representative did not recall consenting to the restraint.
A resident with severe intellectual disabilities and oropharyngeal phase dysphagia was observed lying flat during tube feeding, contrary to the facility's policy requiring a 45 to 90-degree elevation to prevent aspiration. An LPN corrected the positioning after acknowledging the error, and the DON confirmed the expectation for proper bed elevation.
A facility failed to provide proper respiratory care for a resident with COPD due to the absence of a policy for cleaning and storing nebulizer equipment. Observations revealed the nebulizer machine and oxygen mask were not properly cleaned or stored, and the oxygen concentrator was set incorrectly. The DON confirmed the correct procedure was not followed.
A resident with cognitive impairment and mobility issues experienced multiple falls due to the facility's failure to implement effective fall prevention measures. Despite the resident's history of falls, interventions such as using a nonskid pad or locking wheelchair brakes were not consistently applied, leading to incidents where the wheelchair rolled away during transfers.
Missing Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure and document annual performance evaluations for 5 of 5 Certified Nursing Assistants reviewed. Review of the undated facility policy titled Skill Competency Evaluations showed that nurses and CNAs were to have competency evaluations completed during orientation, annually, and as needed by designated staff. However, review of personnel records for all 5 CNAs found no documentation of an annual performance evaluation within the required timeframe. During interviews, the Human Resource Director confirmed that annual competency evaluations had not been completed for the CNAs reviewed, and the Administrator confirmed that although competency evaluations were required annually for nurses and CNAs, they had not been completed as required.
Failure to Provide Routine Hair and Nail Care
Penalty
Summary
The facility failed to ensure a resident received needed assistance with activities of daily living, specifically routine hair and nail care. The resident had diagnoses including anxiety disorder, cerebral infarction, and a history of urinary tract infections, and the MDS showed a BIMS score of 4 out of 15, indicating severe cognitive deficits. The care plan identified an ADL self-care performance deficit related to fatigue, impaired balance, and stroke, and included interventions for extensive assistance with bathing, dressing, transfers, and partial/moderate assistance with personal hygiene and oral care. During observations, the resident was found in bed with dirty fingernails and hair in need of washing, and on subsequent observations the fingernails and hair remained unclean, with the hair described as dirty and matted to the head. The resident’s RP was present feeding the resident during one observation. The Administrator stated she would speak with the nurse about why the resident was not bathed and clean daily. The assigned LPN stated she was not aware the resident had not received a bath on any of the three days observed, and after the concern was brought to attention, the resident’s hands and fingernails were cleaned and the hair was shampooed.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident with diagnoses including Alzheimer's dementia, cognitive communication deficit, and anxiety who was receiving Quetiapine 200 mg at bedtime. The resident's MDS showed a BIMS score of 4 out of 15, indicating severe cognitive deficit. The facility policy stated that residents receiving psychotropic medications should receive GDRs when clinically appropriate unless contraindicated, and that documentation must support when dose reductions are attempted or when there is a clinical rationale for not attempting a reduction. The resident's physician order showed Quetiapine 200 mg nightly had been ordered on admission. The medical record also showed a weight of 86 pounds and documented a history of significant weight changes, along with multiple falls, including a fall with minor injuries, a fall with a left femur fracture, another fall with minor injuries, and a fall with right hip pain. A medication regimen review dated 11/21/2025 recommended evaluating the current dose and considering a dose reduction, but the physician responded, "Resident with good response, maintain the current dose," without resident-specific documentation or clinical rationale for not reducing the dose. During interviews, the pharmacist stated she had recommended a reduction and the physician declined, and the attending physician acknowledged that 200 mg of Seroquel was a large dose for the resident's weight and agreed the weight loss and falls could have been attributed to Quetiapine.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from use and kept separate from in-date medications in 1 of 4 medication carts. During review of the facility policy titled, Medication Labeling and Storage, the nursing staff was identified as responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation of the South Hall medication cart #1, surveyors found one bottle of Aspirin 325 mg tablets, Lot #921X06, that had expired on 01/26/2026. An LPN confirmed the expired medication during interview and removed the bottle from the medication cart.
Out-of-Range Nourishment Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that food stored in the North Unit Hall-100 nourishment room refrigerator was maintained at a safe temperature. During observation, the refrigerator temperature gauge read 46 degrees Fahrenheit and was verified by the kitchen manager. The refrigerator contained nine Mighty Shakes, two Medpass supplement drinks, five Glucerna Shakes, eight Ardmore 100% Orange Juices, and residents' personal food items. The facility policy stated that nourishment room refrigerators are to be maintained at 41 degrees Fahrenheit or below, with daily temperature checks and documentation. Record review showed repeated out-of-range temperatures in the North nourishment refrigerator over multiple days, including readings of 52, 50, 44, 42, 48, and 46 degrees Fahrenheit. Interviews with the kitchen manager, maintenance director, and administrator confirmed the refrigerator temperatures had been out of range and that the issue had been reported to maintenance. The maintenance director stated the refrigerator had been replaced on 02/19/26 and that the thermometer had been changed more than once because the temperature remained out of range. The administrator stated she was not aware the refrigerator temperatures were out of range until informed during the survey.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive deficits was administered medications intended for her roommate. The error took place after the RN had already prepared the medications for the roommate and, while assisting the resident in the restroom, inadvertently gave her the wrong medications. The medications administered included morphine sulfate, quetiapine fumarate, Eliquis, clonidine, docusate sodium, carvedilol, atorvastatin, hydralazine, and gabapentin, none of which were prescribed for the resident who received them. Following the administration of the incorrect medications, the resident exhibited symptoms including feeling sick, a weak pulse, hypotension, and diaphoresis. The RN recognized the error and began monitoring the resident, who subsequently required emergency medical attention. The nurse notified the Unit Manager, who instructed her to contact the physician. The resident was transported to the emergency department, where she was treated for drug overdose and received Narcan and intravenous fluids. The facility's documentation revealed that vital signs were not recorded in the medical record as expected. Both the DON and Unit Manager confirmed that there was no documentation of the resident's vital signs during the incident, despite the expectation that such monitoring should be documented. The incident was determined to be a significant medication error and was cited under pharmacy services for substandard quality of care.
Removal Plan
- MD notified and Resident was sent to the hospital. Resident returned with no adverse effects.
- All residents were assessed by the Director of Nursing with all residents without distress. Vital signs obtained and reviewed for abnormalities, none noted. All residents assessed by Director of Staff Development.
- Roommate MAR reviewed for medication administration. Resident received medications as ordered.
- Resident's names placed outside doors and pictures placed on EMR on every resident. Identification bracelets placed on all residents.
- Inservice on Medication Administration, Medication Errors Policy & Procedures was completed.
- Director of Staff Development and/or designee to provide skills competency to each nurse before next scheduled shift.
- DON to monitor medication administrations skills competencies until compliance has been met.
Expired Medications and Biologicals Found in Storage Rooms
Penalty
Summary
The facility failed to remove expired medications and biologicals from two medication storage rooms, as observed during a survey. In the South Unit's medication storage room, a BD Vacutainer Red Top with an expiration date of 09/30/24 was found. This expired item was verified by an LPN and subsequently removed. In the North Unit's medication storage room, a BD Vacutainer Gel and Lithium Heparin Top with an expiration date of 10/31/24 was discovered. The Director of Nursing (DON) confirmed its expiration and removed it. Additionally, two boxes of Covidien Filac Probe Covers with an expiration date of 08/31/24, each containing 20 probe covers, and one box containing 19 probe covers were also found expired and removed by the DON. Further observations in the North Unit's hallway medication storage revealed three Covidien Kangaroo Epump Sets with Flush 1000 ml, expired since 03/31/23, and one set with an expiration date of 07/31/24. The DON verified these items as expired and removed them from storage. These findings indicate a failure to adhere to the facility's policy of storing medications and biologicals safely, securely, and properly, as per manufacturers' recommendations or those of the supplier.
Inaccurate Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents had accurate and documented Advance Directives, affecting five out of eight residents reviewed. The facility's policy stated that residents have the right to make informed decisions about their medical care, including the right to formulate advance directives. However, discrepancies were found between the residents' hard charts and electronic medical records (EMR), leading to confusion about their code status. For instance, one resident was admitted with a diagnosis of Alzheimer's disease and unspecified dementia. Although a Do Not Resuscitate (DNR) order was found in the resident's hard chart, there was no corresponding code status in the EMR. This inconsistency was confirmed by an LPN, who acknowledged the absence of a code status order in the EMR and stated that an order would be entered. Similarly, another resident's care plan indicated a DNR status, but no physician order was found in the EMR, highlighting a gap in documentation. Additionally, a resident with severe cognitive impairment had conflicting information between their hard chart and EMR regarding their code status. The hard chart indicated a DNR order, while the EMR listed the resident as Full Code. Interviews with staff revealed that the facility had transitioned to a new electronic system, which contributed to the discrepancies. The Director of Nursing and Assistant Director of Nursing expressed expectations for timely updates to the EMR, but acknowledged issues with the transition process.
Failure to Document Restraint Assessment for Resident
Penalty
Summary
The facility failed to complete a restraint assessment for the use of a trunk restraint on a wheelchair for a resident, identified as R47, who was one of four residents reviewed for restraint use. R47, who has severe cognitive impairment with a BIMS score of 3 out of 15, was observed using a lap n lock padded lap desk as a trunk restraint. The resident's medical records did not contain documentation of an assessment for the use of this restraint, which could potentially be considered a restraint. The facility's policy requires orders and assessments for any physical restraints, but these were not found in R47's records. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed the absence of a restraint assessment and consent documentation for R47. The restraint was reportedly implemented after a fall to minimize further injury, but the necessary documentation was not completed or located. The DON later provided a late entry assessment and a handwritten consent form, which lacked a signature and was noted as telephone consent. The resident's representative also did not recall consenting to the use of a restraint. The facility's failure to properly document and assess the use of the restraint led to the deficiency noted in the report.
Improper Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure proper positioning for a resident during tube feeding, which posed a potential risk for aspiration. The facility's policy on gastrostomy tube feeding, revised on 10/10/19, outlines the necessity of placing residents in a Fowler's position to reduce the danger of aspiration. However, during an observation, Resident 107 was found lying on their right side with the bed flat while receiving tube feeding at a rate of 40 ml/hr. This positioning was contrary to the facility's policy, which requires the head of the bed to be elevated between 45 to 90 degrees during feeding. Resident 107, who was admitted with diagnoses including peptic ulcer, severe intellectual disabilities, and oropharyngeal phase dysphagia, had a care plan that emphasized the importance of preventing aspiration. Despite this, the observation revealed a lapse in following the care plan's directive to monitor and report signs of aspiration. During an interview, an LPN acknowledged the incorrect positioning and adjusted the bed accordingly. The Director of Nursing later confirmed that staff are expected to elevate the head of the bed to the appropriate angle after care is completed.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. The resident had a physician's order for Albuterol Sulfate Solution Nebulizer and oxygen therapy. However, the facility did not have a policy for the cleaning and storage of nebulizer machines. During observations, the nebulizer machine was found in the resident's room with the oxygen mask propped against it, not bagged, and with clear liquid in the medication chamber. The oxygen concentrator was set at 2.5 liters per minute, contrary to the resident's statement of being on 2 liters of oxygen. Interviews with the Director of Nursing (DON) revealed that the nebulizer mask and medication chamber should be cleaned with water, air-dried, and stored in a zip lock bag. However, this procedure was not followed, as evidenced by the observations of the nebulizer equipment not being properly cleaned or stored. The lack of a facility policy and the improper handling of the nebulizer equipment led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement an appropriate fall intervention for a resident, leading to multiple incidents where the resident fell from their wheelchair. The resident, who had a medical history of gait and mobility abnormalities, dementia, osteoporosis, osteoarthritis, and muscle weakness, was admitted to the facility in May 2021. The resident's care plan identified a potential for falls due to limited mobility and other health issues, yet the interventions in place were insufficient to prevent the wheelchair from rolling away during transfers. The resident experienced several falls, including incidents where the wheelchair rolled from underneath them, resulting in minor injuries such as lacerations and bruising. Despite these incidents, the facility did not implement effective interventions to prevent the wheelchair from rolling. The facility's accident reports noted that interventions like using a nonskid pad or locking the wheelchair brakes were considered but not implemented. The resident's cognitive impairment further complicated the situation, as they were unable to remember to lock the wheelchair independently. Interviews with facility staff, including the Director of Nursing and the Physical Therapy Assistant, revealed that the facility did not have a consistent approach to addressing the resident's fall risk. The staff acknowledged the need for better interventions but did not have a system in place to ensure that effective measures were implemented promptly. The lack of immediate and appropriate interventions contributed to the ongoing risk of falls for the resident.
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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