Heritage Home Of Florence Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, South Carolina.
- Location
- 515 South Warley Street, Florence, South Carolina 29501
- CMS Provider Number
- 425154
- Inspections on file
- 19
- Latest survey
- February 7, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Heritage Home Of Florence Inc during CMS and state inspections, most recent first.
A resident with a history of respiratory failure, who had been receiving supplemental O2 in the facility, was discharged home without discharge paperwork or supplemental O2. The responsible party had informed staff in advance of the planned discharge and was told paperwork would be ready, but when they arrived, no discharge documents were available and attempts by nursing staff to obtain them were unsuccessful. The resident left without discharge instructions, and the SW later confirmed that although the resident had received supplemental O2 in the facility, no O2 order was sent home. Discharge instructions were instead reviewed with the responsible party by phone several days after the resident had already left.
The facility did not follow its policy requiring weekly body audits and wound measurements for a resident admitted with an unstageable sacral pressure ulcer and severe cognitive impairment. Although staff, including LPNs, the wound care nurse, and the DON, stated that weekly skin audits and wound assessments were performed and documented in the EHR, the medical record contained only a single Skin & Wound Evaluation from admission with no subsequent documented skin checks or wound measurements during the resident’s stay.
The facility failed to remove expired medications from a medication cart and storage room, and did not secure the medication room properly, allowing unauthorized access by unlicensed personnel. Expired medications, including suppositories and Hydrocodone-Acetaminophen tablets, were found and verified by LPNs. Unauthorized access was observed when a CNA entered the medication room to use a microwave, a practice confirmed to be ongoing for years. The DON acknowledged that only licensed nurses should have access, but both licensed and unlicensed staff had the code to the room.
A resident with multiple diagnoses, including anemia and osteoporosis, did not receive the ordered House Shake supplement for weight gain, despite experiencing significant weight loss. Observations showed the resident received ice cream but not the House Shake. Interviews revealed communication and documentation lapses, as the supplement was not listed on meal tickets or the MAR, leading to the dietary staff not providing it.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The RN did not sanitize her hands between multiple glove changes, violating the facility's infection control policy. Interviews confirmed the lapse in protocol adherence, highlighting a deficiency in infection prevention practices.
Failure to Provide Discharge Instructions and Supplemental Oxygen at Discharge
Penalty
Summary
The facility failed to provide a discharge summary and supplemental oxygen at the time of discharge for one resident. Facility policy titled "Discharge Summary and Plan" required that, when discharge was anticipated, a discharge summary and post-discharge plan be developed and that a copy of the evaluation of discharge needs, the post-discharge plan, and the discharge summary be provided to the resident and receiving facility, with a copy filed in the medical record. The resident, who had a medical history including respiratory failure, was admitted on 11/07/2025 and discharged home with home health services on 11/27/2025. The resident’s responsible party reported notifying the Admissions Coordinator the day before discharge that the resident would be going home and was told discharge paperwork would be ready at pickup. When the responsible party arrived to take the resident home, the facility did not have the discharge paperwork available, and although a nurse attempted to contact someone to obtain it, they were unsuccessful. The responsible party left the facility with the resident without any discharge paperwork. The resident had been receiving supplemental oxygen while in the facility, but the responsible party stated the resident was discharged without supplemental oxygen. The Social Worker reported that her usual process at discharge was to set up home health, print durable medical equipment orders, and provide discharge paperwork at the time of discharge, but she was not working during the resident’s holiday-weekend discharge. She believed the discharge paperwork was mailed and confirmed that on 12/01/2025 she reviewed the discharge paperwork with the responsible party by phone, four days after discharge. The Social Worker stated that if a resident received supplemental oxygen in the facility, they would be discharged with an order for supplemental oxygen, and confirmed that this resident had received supplemental oxygen in the facility but had no orders for supplemental oxygen at discharge. Review of the Discharge Instruction Form showed it was signed by the Social Worker and dated 12/01/2025, with a handwritten note indicating the instructions were discussed verbally with the responsible party on that date. The DON and Administrator both stated their expectation that residents receive education, medications, post-discharge arrangements, and discharge paperwork at the time of discharge.
Failure to Perform and Document Weekly Skin Audits and Wound Measurements
Penalty
Summary
The facility failed to provide weekly body audits and wound measurements as required by its own policy and the resident’s care plan for a resident with an unstageable sacral pressure ulcer. The facility’s Pressure Injury/Wound/Skin Management policy dated 08/2016 required a licensed nurse to perform weekly body audits, wound measurements, and document findings in the medical record. The resident was admitted with an unstageable sacral pressure ulcer, documented on the admission record and baseline care plan, which identified impaired skin on the sacrum and directed staff to perform weekly skin checks. The admission MDS showed the resident had severe cognitive impairment with a BIMS score of 7/15 and one unstageable pressure ulcer present on admission. Record review showed only one Skin & Wound Evaluation dated on the admission date, documenting the sacral wound size and tissue characteristics, with no further documented skin checks or wound measurements for the remainder of the resident’s stay until discharge. Multiple LPNs, including the wound care nurse, reported in interviews that weekly skin audits were conducted and documented in the EHR, and that the wound nurse was responsible for weekly wound measurements with the wound physician. However, the wound care nurse acknowledged she did not know why this resident’s measurements were not documented, and the DON confirmed that the facility could not locate any wound documentation beyond the initial evaluation, despite her expectation that wounds be measured and documented weekly.
Expired Medications and Unauthorized Access in Medication Storage Room
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in expired medications and biologicals being present in the medication storage room and on a medication cart. During observations, expired Rugby Hemorrhoidal Suppositories and BD Vacutainer Safety-Lok Blood Collection Sets were found in the Chestnut Medication Storage Room. Additionally, Hydrocodone-Acetaminophen tablets were found expired on the Chestnut Front Hall Cart. Licensed Practical Nurses verified the expiration of these items and removed them from their respective locations. The facility also failed to secure the medication storage room properly, allowing unauthorized access by unlicensed personnel. A Certified Nursing Assistant (CNA) was observed entering the medication storage room to use a microwave, which was confirmed to be a common practice. The CNA accessed the room using a code, which was known to other unlicensed staff, including housekeepers who entered the room to clean the microwave. This practice had been ongoing for several years, as confirmed by the staff. The Director of Nursing (DON) acknowledged that only licensed nurses should have access to the medication room. However, it was revealed that both licensed and unlicensed staff had the code to the room, and stock medications were stored in unlocked cabinets. The DON admitted to not considering the accessibility of stock medications and focused only on the requirement for narcotics to be double locked. The practice of storing stock medications in the room began after a pharmacy switch in 2020.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident, identified as R50, with the ordered nutritional supplements, specifically the House Shake, as part of her dietary needs. R50, who was admitted with diagnoses including anemia, hyperlipidemia, cerebral infarction, anxiety, gastroesophageal reflux, and osteoporosis, experienced unintentional weight loss of 10.40% over 180 days. Her dietary plan included receiving nutritional supplements twice a day, including a House Shake at lunch and dinner. However, observations on multiple occasions revealed that R50 did not receive the House Shake as ordered, although ice cream was consistently provided. Interviews with facility staff, including the Dietary Manager and the Director of Nursing, revealed a lack of communication and documentation regarding the provision of the House Shake. The Dietary Manager noted that the House Shake was not listed on R50's meal ticket, which led to the dietary staff not providing it. The Director of Nursing confirmed that the House Shake was not recorded on the medication administration record (MAR) for nurses to verify its delivery. The Unit Manager stated that the order for the House Shake was placed, but it was not communicated effectively to ensure R50 received it.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The facility's policy on wound care and dressing change procedures requires hand hygiene to be performed after removing gloves and before applying new ones. However, during an observation of wound care for a resident, the registered nurse (RN) did not follow these procedures. The RN was observed performing wound care without sanitizing her hands between multiple glove changes, which is a violation of the facility's infection prevention and control program. The resident involved in this deficiency was admitted with multiple diagnoses, including dementia, depression, Alzheimer's disease, dysphagia, and hypertension. The resident had a treatment order to cleanse a sacral wound with normal saline, apply Medi-honey and calcium alginate, and cover it with a dry dressing. During the wound care observation, the RN cleaned the wound, applied treatments, and changed gloves several times without performing hand hygiene, despite the presence of a foul odor and a deep crater in the wound. Interviews with the RN, the Unit Manager, and the Director of Nurses confirmed the failure to adhere to hand hygiene protocols. The RN acknowledged that she should have sanitized her hands between glove changes, and both the Unit Manager and the Director of Nurses stated that hand hygiene is required after removing gloves during dressing changes. This deficiency highlights a lapse in following established infection control procedures, which are critical for preventing the spread of infection in long-term care settings.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
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