Lake Emory Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Inman, South Carolina.
- Location
- 59 Blackstock Road, Inman, South Carolina 29349
- CMS Provider Number
- 425303
- Inspections on file
- 25
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lake Emory Post Acute Care during CMS and state inspections, most recent first.
A resident with severe dementia, daily wandering, and a high fall risk experienced multiple falls with serious injuries over several months, while care plan interventions remained limited to basic measures such as nonskid strips, clothing adjustments, and redirection. The resident’s room was located near an exit and away from the nurse’s station, and the resident was known by CNAs to be impulsive and ambulatory, often attempting to walk without assistance. On one occasion, staff left a large rolling trash can in the hallway near the resident’s room, despite training that it should be stored in the shower room; the resident attempted to use it for support, it rolled away, and the resident fell, sustaining a right femur fracture. This sequence of events reflects the facility’s failure to identify and remove an environmental hazard for a resident with a known history of falls.
A resident with moderate dementia verbally abused their severely cognitively impaired roommate, using profane and derogatory language in front of the roommate's family. The incident was reported to an LPN and the DON, and a grievance was filed, but the required report to the State Agency was not made within the mandated timeframe because staff did not initially recognize the incident as abuse.
Two cognitively impaired residents eloped from a facility after being let out unsupervised by an RN. Despite having a history of wandering and requiring wander guards, the residents were allowed to leave with other smokers. They were found by emergency services about a mile away after being missing for approximately an hour. The incident revealed a lack of communication and adherence to elopement prevention protocols among staff.
Two cognitively impaired residents eloped from an LTC facility after an RN allowed them to exit unsupervised. Despite having wander guards and being identified as elopement risks, the residents were found a mile away by emergency services. The incident revealed a failure in supervision and adherence to safety policies.
Two residents with severe cognitive impairment eloped from the facility without supervision and were not reported to their responsible parties. The residents, who were allowed to exit unsupervised by an RN, were found a mile away. The facility's policy requires notifying the responsible parties, but no documentation of such notifications was found.
The facility failed to ensure foods in the refrigerator and nourishment kitchen were free from expiration. Observations revealed expired lettuce and milk, which were overlooked by staff. The Dietary Manager confirmed the oversight, and the Facility Administrator emphasized the importance of discarding expired items.
Failure to Remove Environmental Hazard for High-Risk Fall Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with a known history of frequent falls and severe cognitive impairment. The resident was admitted with diagnoses including a displaced left humerus fracture, severe dementia with anxiety, and muscle weakness, and was assessed as a high fall risk with a Morse Fall Scale score of 50. MDS assessments documented severe cognitive impairment (BIMS 00/15 and later unable to complete), daily wandering, delusional behaviors, inattention, disorganized thinking, and both short- and long-term memory loss. The resident was described as active, ambulatory, and impulsive, with a pattern of attempting to stand or ambulate without assistance and requiring consistent redirection. Between late August and mid-December, the resident experienced ten documented falls, three of which resulted in major injuries, including a nasal fracture, a subdural hemorrhage with a right clavicle fracture, and later a right femur fracture. Progress notes described multiple unwitnessed and witnessed falls in various locations, including another resident’s room, during ambulation to the shower room, behind the nurse’s station, in front of the wheelchair in the dining room, at the nurse’s station, and in the hallway. Despite this pattern of falls and injuries, the fall care plan interventions remained limited to measures such as ensuring proper pants length, using nonskid strips, offering redirecting activities, removing slippers from the room, placing a resident identifier outside the room, and assisting or redirecting the resident when seen walking without assistance. On the date of the cited incident, staff left a large grey rolling trash receptacle in the hallway near the exit door by the resident’s room, contrary to staff training that the trash can must be kept in the shower room and not left in hallways except when being emptied into the dumpster. The resident, known to be impulsive and ambulatory, exited the room, attempted to use the rolling trash can for support, and fell when it rolled away, striking the rail and holding the right upper thigh, with a subsequent diagnosis of a right femur fracture. The room’s location near an outside exit door and far from the nurse’s station, combined with the resident’s established fall history and behaviors, and the presence of the rolling trash can in the hallway, constituted the facility’s failure to identify and remove an environmental hazard for a high-risk resident.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident mental abuse to the State Agency as required by its own policy and federal regulations. The incident involved a resident with moderate vascular dementia and psychotic disturbance (the aggressor) verbally abusing their roommate, who had severe cognitive impairment. The aggressor used profane language, made derogatory remarks about the roommate, and demanded that the roommate and their family leave the shared room. The roommate's family member, visibly upset and concerned for the resident's safety, reported the incident to nursing staff and filed a grievance. Facility documentation shows that the incident occurred when the family member brought the resident back to their room and was met with verbal hostility from the roommate. The nurse on duty reported the incident to the DON, and the roommate was moved to another room. The family member completed a grievance form, which was submitted to the Social Service Director. However, the initial report to the State Agency was not completed until the following day, outside the required reporting timeframe for abuse allegations that do not result in serious bodily injury. The facility's policy mandates immediate reporting of abuse allegations, but staff did not recognize the incident as abuse at the time, partly because the family member did not explicitly use the term "abuse." The DON was notified, and the grievance was documented, but the delay in recognizing and reporting the incident resulted in a failure to meet the required reporting timeline. The administrator later acknowledged that the incident should have been reported on the day it occurred, regardless of the terminology used by the family member.
Neglect Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that two residents, identified as R2 and R3, were free from neglect, resulting in their successful elopement from the facility. Both residents were severely cognitively impaired, with BIMS scores of 6 out of 15, indicating severe cognitive impairment. R2 had a history of wandering and was not oriented to her surroundings, requiring supervision and a wander guard. Similarly, R3 was not oriented to place or time and had a history of wandering, also requiring a wander guard. Despite these precautions, both residents were allowed to leave the facility unsupervised. On the evening of the incident, a Registered Nurse (RN) on duty let R2 and R3 out the back door along with other smokers, without any escort or supervision. The RN assumed the residents were competent to be outside unsupervised. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM. During this time, the facility staff, including the Assistant Director of Nursing (ADON) and several Certified Nursing Assistants (CNAs), were alerted to the residents' absence and began searching for them. The residents were eventually found by emergency services about a mile down the road, having been gone for approximately an hour. Interviews with facility staff revealed a lack of communication and proper protocol in handling the situation. The CNA who discovered the residents were missing reported the incident to the RN, who initially refused to call for assistance until a thorough check of the facility was completed. The ADON was notified and arrived at the facility to assist in the search. The residents were found by following emergency vehicles that had responded to a call about the residents being seen on the road. The incident highlighted a significant lapse in supervision and adherence to the facility's elopement prevention policies.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide appropriate supervision to prevent the elopement of two residents, identified as R2 and R3, from the facility. Both residents were severely cognitively impaired, with R2 having a history of wandering and requiring a wander guard. On the evening of the incident, an RN allowed R2 and R3 to exit the facility through the back door along with other residents who intended to smoke, without any escort or supervision. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM, having been found by emergency services about a mile away from the facility. R2 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. R2's care plan indicated she was an elopement risk and required a wander guard. Similarly, R3 was admitted with vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease. R3's care plan also included the use of a wander guard. Despite these precautions, both residents were able to leave the facility unsupervised, which was a significant oversight in their care. Interviews with facility staff revealed a lack of immediate action when the residents were discovered missing. The Assistant Director of Nursing was informed of the situation and arrived at the facility to assist in the search. The residents were eventually located by following emergency services vehicles, which had responded to a call about the residents. The incident highlighted a failure in the facility's elopement prevention measures and the need for staff to adhere strictly to policies regarding resident supervision and safety.
Failure to Notify Responsible Parties of Resident Elopement
Penalty
Summary
The facility failed to notify the responsible parties of two residents, identified as R2 and R3, following an elopement incident. According to the facility's policy on elopement, the Director of Nurses or their designee is required to notify the Administrator, appropriate community agencies, the attending physician, and the resident's legal representative when a resident is located after an elopement. However, in this case, there was no documentation in the progress notes of either resident indicating that their responsible parties were informed of the elopement. Both residents were severely cognitively impaired, with BIMS scores of 6 out of 15, and had diagnoses including vascular dementia and major depressive disorder. The incident occurred when an RN allowed R2 and R3 to exit the facility unsupervised along with other smokers. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM, having been located about a mile from the facility. Interviews with the Administrator and the responsible parties for R2 and R3 revealed that neither the residents' family members nor their legal representatives were informed of the elopement. The Administrator acknowledged that the notification responsibility typically falls to the nursing staff, and there was no record of such notifications being made in this instance.
Expired Food Items Found in Facility's Kitchen and Nourishment Kitchen
Penalty
Summary
The facility failed to ensure that foods stored in the refrigerator and nourishment kitchen were free from expiration, as observed during a survey. The facility's policy required that all products be properly labeled and dated, but during observations, it was found that two clear bags containing a total of 12 heads of lettuce were not labeled with an open date and had a use-by date that had passed. The lettuce was observed to be brown with pink build-up, indicating spoilage. Additionally, in the nourishment kitchen, three cartons of Dairy Pure 1% low-fat milk were found with an expiration date that had already passed. Interviews with the Dietary Manager (DM) revealed that staff are expected to check for expired foods in all storage areas, but the expired items were overlooked. The DM acknowledged that the heads of lettuce were at the bottom and missed during checks. The DM also confirmed that the expired milk did not belong in the refrigerator. The Facility Administrator expressed that her expectation was for all items to be discarded by their use-by dates to prevent compromising other foods.
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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