Iva Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Iva, South Carolina.
- Location
- 406 West Broad Street, Iva, South Carolina 29655
- CMS Provider Number
- 425317
- Inspections on file
- 17
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Iva Post-acute during CMS and state inspections, most recent first.
A resident with acute respiratory failure and hypoxia did not receive oxygen therapy as ordered, with observations showing oxygen administered at a higher flow rate than prescribed and tubing not changed according to the physician's schedule. Documentation by nursing staff did not match actual practice, and both an LPN and the DON confirmed the discrepancies in oxygen administration and tubing change frequency.
A resident with ESRD who required hemodialysis did not receive scheduled morning medications on multiple dialysis days, despite physician orders allowing for adjusted administration times. An LPN withheld all medications except pain medication and did not clarify the order, while the DON was unaware of the specific instructions, resulting in missed doses.
Staff did not adhere to Enhanced Barrier Precautions (EBP) when providing indwelling urinary catheter care for two residents with urinary retention, using only gloves instead of the required gowns and face shields. Despite facility policy and staff training on EBP, staff demonstrated inconsistent understanding and failed to implement the necessary PPE during catheter care, as confirmed by interviews and observations. The DON stated that staff were expected to follow EBP protocols and report PPE shortages, but this did not occur.
The facility failed to provide the correct Medicare Part A Advanced Beneficiary Notice of Non-coverage to two residents when their services were ending. Instead, they received a form intended for Medicare Part B services. This error was confirmed by the Business Office Manager and Assistant Business Office Manager, who admitted to using the incorrect form due to a lack of proper documentation.
A resident with severe cognitive impairment received medication through an enteral feeding tube without following the facility's protocol. An LPN failed to use a towel or Chux pad and did not verify tube placement, leading to contamination of the syringe. The DON acknowledged the protocol breach.
A facility failed to ensure proper communication with a dialysis center for a resident with ESRD. The facility's policy and agreement require information exchange for resident care, but records for specific dialysis sessions were missing. Interviews with staff revealed that communication forms are supposed to be completed by the dialysis center and returned, but some were missing, leading to the deficiency.
The facility did not include a Registered Nurse (RN) on the daily staff postings for March, June, and July 2024. The staffing sheets lacked a designated RN for at least eight hours, as required. The Operation Manager noted that the HR officer, who was new, took over the task of completing the postings and failed to include RN hours.
The facility failed to remove outdated or improperly labeled medications and biologicals from a treatment cart. During an observation, several items were found to be opened and no longer sterile, and some were expired. The facility's policy requires proper labeling and removal of expired items, but these procedures were not followed. The findings were verified by an LPN and acknowledged by the DON.
A facility failed to coordinate care between hospice services and its staff for a resident with multiple diagnoses, including a cerebrovascular accident. Despite receiving hospice care, the facility did not document hospice visit assessments in the resident's medical record, which should have included findings for progress or necessary care plan changes. The Director of Nursing noted that daily assessments were sent by the hospice but were not placed in the hospice binder, leading to a lack of documented communication and coordination.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of acute respiratory failure with hypoxia did not receive oxygen therapy according to physician orders. The physician's order specified oxygen at 2 liters per minute (LPM) via nasal cannula continuously and required the oxygen tubing to be changed weekly on Wednesdays. However, observations revealed that the resident was receiving oxygen at 3 LPM, and the oxygen tubing in use was dated nearly two weeks prior, indicating it had not been changed as ordered. Documentation in the Treatment Administration Record confirmed that nursing staff recorded the resident as being on 2 LPM, but direct observation contradicted this, showing the oxygen set at 3 LPM. During interviews, an LPN acknowledged the discrepancy in both the oxygen flow rate and the tubing change schedule, stating tubing was changed every three days rather than weekly. The DON confirmed that staff were expected to check oxygen settings every shift and change tubing weekly, but these practices were not followed for this resident.
Failure to Administer Scheduled Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) who required hemodialysis received their scheduled morning medications either before or after returning from dialysis. Review of the resident's care plan and physician orders indicated that medication administration times on dialysis days could be adjusted to ensure proper absorption, but the September Medication Administration Record showed that several medications, including amlodipine, Aricept, and duloxetine, were not administered on multiple dialysis days. The facility's policy required staff to be trained in the timing and administration of medications for residents receiving dialysis, but this was not followed in practice. Interviews revealed that the LPN responsible for the resident's care withheld all medications except pain medication on dialysis days and did not administer them when the resident returned. The LPN also stated that she did not seek clarification regarding medication administration for the resident on dialysis days. Additionally, the DON was unaware of the specific order allowing for medication time adjustments and believed all medications were to be held on dialysis days. This lack of communication and adherence to physician orders resulted in the resident missing scheduled doses of essential medications.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines regarding Enhanced Barrier Precautions (EBP) during the provision of indwelling urinary catheter care for two residents with urinary retention and indwelling catheters. Facility policy required the use of EBP, including wearing gowns, gloves, and face shields during device care for residents with indwelling catheters. However, during multiple observations, staff members performed catheter care using only gloves and did not wear gowns or face shields as required. Interviews with certified nurse aides revealed inconsistent understanding and application of EBP protocols, with some staff believing gowns were only necessary for residents with wounds, and others acknowledging they should have worn additional PPE but did not obtain it prior to providing care. The residents involved had documented orders and care plans specifying the need for catheter care and EBP due to their indwelling urinary catheters. Despite receiving training on EBP, staff did not consistently implement the required precautions. The Director of Nursing confirmed that staff were expected to follow EBP protocols and to notify management if PPE was unavailable, but this expectation was not met during the observed care events.
Incorrect Medicare Part A Notice Issued to Residents
Penalty
Summary
The facility failed to issue the correct Medicare Part A Advanced Beneficiary Notice of Non-coverage (SNFABN) to two residents, R28 and R35, when their Medicare Part A services were ending. Instead of providing the required CMS Form-10055, the facility issued Form CMS-R-131, which is intended for Medicare Part B services. This error occurred despite the fact that both residents were still in the facility and had not exhausted their benefit days under Medicare Part A. The deficiency was confirmed during an interview with the Business Office Manager and the Assistant Business Office Manager, who acknowledged that the incorrect form was used. They stated that CMS-R-131 was the only form they had been using, along with CMS-10123, which informed the residents of the last day of their Medicare Part A Skilled Services. This oversight affected two out of three residents reviewed for advanced beneficiary notices, indicating a systemic issue in the facility's process for handling Medicare Part A service terminations.
Improper Medication Administration via Enteral Feeding Tube
Penalty
Summary
The facility failed to ensure the safe administration of medications through an enteral feeding tube for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Parkinson's Disease with Dyskinesia, was observed receiving medication through a feeding tube without adherence to the facility's established protocol. The facility's policy requires specific preparation and procedural steps, such as using a towel or Chux pad and verifying tube placement, to ensure safe medication administration. During an observation, an LPN administered Vancomycin HCL to the resident without placing a towel on the bed or bedside table and failed to check the tube placement before administering the medication. The LPN placed the syringe on the bare sheet and later discarded it due to contamination. The Director of Nursing acknowledged the lapse in protocol and indicated that an in-service on tube feeding would be conducted to address the issue.
Failure in Communication Between Facility and Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication between the nursing facility and the dialysis center for a resident with End Stage Renal Disease (ESRD), identified as R10. The facility's policy and agreement with the dialysis center require the exchange of information necessary for the care of residents with ESRD, including the use of a communication form. However, records for R10's dialysis sessions on specific dates were missing, indicating a lapse in the communication process. The facility's policy, revised in 2010, and the SNF Dialysis Services Agreement from 2011, both emphasize the importance of documented collaboration and communication between the nursing facility and the dialysis unit. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the Medical Records Coordinator, revealed the process for handling communication forms when a resident goes to dialysis. The forms are supposed to be completed by the dialysis center and returned to the facility, where they are then sent to medical records. However, the Medical Records Coordinator confirmed that some forms were missing, and they had to contact the dialysis center to retrieve them. This breakdown in communication and documentation led to the deficiency noted in the report.
Failure to Include RN Hours on Daily Staff Posting
Penalty
Summary
The facility failed to include a Registered Nurse (RN) on the daily staff posting for the months of March, June, and July 2024. This deficiency was identified through observations, record reviews, and interviews. The daily staffing sheets for each shift during these months did not list a designated RN for at least eight hours, as required. A line on the staffing sheets indicated where RN hours should be recorded, but this section was left blank. During an interview, the Operation Manager acknowledged that RN hours should be included on the daily staff posting. The Operation Manager explained that they had been responsible for completing the daily staff postings in January and February, but the task was later assigned to the Human Resource (HR) officer, who was new to the facility. The Operation Manager was unsure why the HR officer did not include the RN hours.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals that were outdated or without proper labeling were removed from the medication treatment cart. During an observation of the Unit 100/200 Treatment Cart, several items were found to be opened and no longer sterile, including Maxorb II AG Alginate Wound Dressing, Opticell Chitosan-Based Gelling Fiber, MediHoney Hydrogel, and others. Additionally, some items were expired, such as the MediHoney Hydrogel and Maxorb II alginate wound dressing. The facility's policy on the storage of medications, revised in November 2020, requires that drug containers with missing, incomplete, improper, or incorrect labels be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed. However, during the observation, it was noted that these procedures were not followed, leading to the presence of expired and improperly labeled items in the treatment cart. The findings were verified by an LPN and later acknowledged by the Director of Nursing, who stated that all nurses should check for expired medications.
Failure in Coordination of Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care between hospice services and the facility for a resident receiving hospice care. The facility's policy outlined responsibilities for both the hospice and the facility, including the hospice managing the resident's care related to the terminal illness and the facility meeting the resident's personal care and nursing needs in coordination with the hospice. However, the facility did not have documentation of hospice visit assessments in the resident's medical record, which should have included findings during assessments for progress, decline, or necessary changes to the care plan. The resident in question was admitted to the facility with multiple diagnoses, including cerebrovascular accident, chronic viral hepatitis C, and anxiety, and was receiving hospice care for the cerebrovascular accident. Despite the hospice entity sending daily assessments to the facility, these assessments were not placed in the hospice binder as required, leading to a lack of documented communication and coordination between hospice and facility staff. The Director of Nursing acknowledged that the assessments should have been available to ensure continuity of care 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.
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