Magnolia Manor - Greenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, South Carolina.
- Location
- 411 Ansel St, Greenville, South Carolina 29601
- CMS Provider Number
- 425090
- Inspections on file
- 24
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Magnolia Manor - Greenville during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A Housekeeping Supervisor handled soiled linen without donning a gown, as required by facility policy, during laundry processing. The staff member wore goggles and gloves but failed to use a gown, later acknowledging the omission. The Administrator confirmed that proper PPE use is expected for all laundry staff.
A significant pest infestation was observed in both staff and resident areas, including a large number of antlike insects in a conference room and brown bugs in a resident's bathroom. Staff confirmed the presence of pests and described them as a recurring issue, particularly in the summer. The facility's pest control policy requires regular inspections and prompt reporting, but the observed response did not fully align with these procedures.
Surveyors identified that insulin pens and prefilled syringes were not consistently labeled with open or expiration dates, and some unopened insulin products were not refrigerated as required. Nursing staff interviews confirmed that responsibility for labeling and storage was shared among pharmacy, unit managers, and nurses, but lapses occurred, including expired and unlabeled insulin remaining on medication carts.
A resident with dementia and behavioral issues did not receive timely psychiatric services despite a physician's order. The resident, who speaks only Spanish, exhibited aggressive behaviors and required frequent redirection. Facility staff were unclear about the status of the psychiatric referral, leading to a deficiency in providing appropriate mental health services.
The facility failed to complete dialysis communication sheets for three residents, leaving sections blank that are crucial for ongoing communication with the dialysis center. Despite receiving dialysis reports, staff did not document pre- and post-dialysis care, including shunt checks, as required by facility policy. Interviews revealed challenges in obtaining completed sections from the dialysis center and acknowledged incomplete documentation.
An LPN failed to follow the facility's policy for administering medications via enteral feeding tube, resulting in improper medication administration for a resident. The LPN did not perform required water flushes before, between, and after medications, leading to a clogged tube during the process. The incident was confirmed by the Administrator and Regional Clinical Manager.
A resident with multiple health issues, including left-sided hemiparesis, experienced inadequate ADL care due to overgrown fingernails causing pain. Despite attempts to address the issue through dermatology and podiatry referrals, the facility lacked the necessary equipment and expertise to manage the resident's nail care effectively, leading to ongoing discomfort.
A resident experienced a medication administration error due to an LPN's failure to follow the facility's policy for administering medications via enteral feeding tube. The LPN did not flush the gastric tube with water before, between, and after administering medications, leading to a 19% medication error rate and a clogged tube during Nexium administration.
A facility failed to ensure an LPN followed PPE protocols while administering medication via a gastric tube to a resident. Despite a policy requiring enhanced barrier precautions (EBP) to prevent MDRO transfer, the LPN did not wear a gown during the procedure. The LPN admitted to forgetting the requirement, and the facility acknowledged challenges in staff adherence to EBP despite ongoing training.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Proper PPE Use During Soiled Linen Handling
Penalty
Summary
The facility failed to ensure proper handling and processing of resident laundry in accordance with its infection prevention and control policies. During an observation, the Housekeeping Supervisor was seen handling soiled linen while wearing goggles and gloves, but did not don a gown as required by facility policy. The soiled linen was separated, the clear bags were discarded, and the soiled linen cart was pushed to the washing machine, where the linen was loaded without the use of a gown. The facility's policy specifies that personnel must wear gowns and gloves when handling soiled linens to prevent contamination. In an interview, the Housekeeping Supervisor acknowledged forgetting to wear a gown, stating nervousness as the reason and recognizing the requirement to always wear a gown when handling soiled laundry. The Administrator confirmed that the expectation is for laundry staff to apply and wear the correct PPE as outlined in the policy. No residents or specific patient conditions were mentioned in relation to this deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which mandates regular inspections, detailed reporting of pest activity, and prompt response to pest sightings. During an observation, a significant infestation of small, light brown antlike insects was found in the conference room, including on the walls, floor, and in the personal belongings of the survey team. The maintenance staff responded by treating the area with an over-the-counter insect spray, and the survey team was relocated. Additionally, four brown bugs were observed crawling in a resident's bathroom, and the Unit Manager confirmed their presence, indicating that maintenance would be notified to address the issue. Interviews with staff revealed that pest sightings, including roaches, are considered common in the building, especially during the summer. The Administrator stated that the facility contracts with Ecolab for monthly pest control services and expects staff to report pest sightings so that Ecolab can be called for additional treatment as needed. However, the observations and staff interviews indicate that pests were present in resident and staff areas, and the response to these sightings did not align with the facility's policy for pest management and reporting.
Failure to Properly Label and Store Insulin Medications
Penalty
Summary
The facility failed to ensure that insulin medications were properly labeled and stored according to professional standards and facility policy. During observations of two medication carts, surveyors found multiple insulin pens in use without open or expiration dates documented, as well as insulin pens that were expired but still present on the cart. Additionally, unopened prefilled insulin syringes and pens were found unrefrigerated, contrary to storage requirements. The facility's own policy requires all medications to be labeled with expiration dates and appropriate instructions, and for insulin pens, the date opened must be written on the pen to ensure use within the recommended timeframe. Interviews with nursing staff revealed that while pharmacy staff are responsible for placing medications in the refrigerator during their bi-monthly visits, it is the responsibility of the unit manager and nurses to check the carts and ensure proper labeling and storage. However, lapses were identified, such as insulin pens without open dates, expired pens not removed in a timely manner, and unopened insulin not being refrigerated. The Director of Nursing confirmed that education on insulin management is provided by the Interventionist Nurse or unit manager, but at the time of the survey, the Interventionist Nurse was on leave.
Failure to Provide Timely Psychiatric Services for Resident with Dementia
Penalty
Summary
The facility failed to provide timely behavioral and mental health services to a resident diagnosed with dementia, anxiety disorder, and major depressive disorder. The resident, who speaks only Spanish, exhibited behavioral symptoms such as restlessness, agitation, and aggression towards others. Despite a physician's order for psychiatric consultation dated July 1, 2024, the resident had not been evaluated by psychiatric services by the time of the report, which was several months later. Throughout the resident's stay, there were multiple incidents of aggressive behavior, including attempts to exit the building, physical altercations with other residents, and resistance to redirection by staff. The facility's staff attempted to manage these behaviors with medication and redirection techniques, but the language barrier and lack of timely psychiatric intervention hindered effective management. The resident's behavior continued to escalate, leading to further incidents and the need for frequent monitoring and intervention by nursing staff. Interviews with facility staff, including the ADON and Social Services Director, revealed a lack of clarity and documentation regarding the psychiatric referral process. The Social Services Director was unable to provide documentation of when the referral was made, and the Nurse Practitioner was under the impression that the resident was already being followed by psychiatric services. This lack of coordination and follow-through contributed to the deficiency in providing appropriate mental health services to the resident.
Incomplete Dialysis Communication Sheets
Penalty
Summary
The facility failed to ensure proper completion of dialysis communication sheets, which are essential for ongoing communication between the facility staff and the dialysis center. This deficiency was observed in three out of four sampled residents who required dialysis care. The facility's policy mandates that staff use the Dialysis Communication Form to document pre- and post-dialysis care, including checking the shunt for bruit. However, several sections of these forms were left blank, particularly the sections related to the shunt site and the documentation of thrills and bruits. This lack of documentation was noted across multiple dates for the residents involved, indicating a pattern of incomplete record-keeping. The residents affected by this deficiency had significant medical conditions, including End-Stage Renal Disease and Chronic Kidney Disease, necessitating regular dialysis. Despite receiving dialysis reports from the dialysis center, the facility staff failed to complete the necessary documentation on the communication sheets. Interviews with the Director of Nursing revealed challenges in obtaining completed sections from the dialysis center and acknowledged the need for complete documentation if the forms were to be used for communication. The Regional Clinical Nurse also noted that some nurses were documenting shunt checks in progress notes rather than on the communication sheets, contributing to the incomplete records.
Failure to Follow Enteral Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice via enteral feeding tube for a resident. The facility's policy on Enteral Feeding-Administering Medications required that medications be given with appropriate water flushes before, between, and after administration. However, an LPN did not adhere to this policy while administering medications to a resident with a gastric tube. The LPN did not bring additional water for flushing into the resident's room and failed to flush the gastric tube before administering medications, between each medication, and after completing the medication administration. During the medication administration, the LPN used a clean 60 ml syringe to administer medications by gravity, but the Nexium solution caused the tubing to become clogged. The LPN massaged the tubing until the clog was dislodged and continued with the administration. The LPN also rinsed the syringe in the resident's sink, which was not in line with the facility's policy. The failure to follow the prescribed procedure was confirmed during an interview with the Administrator and the Regional Clinical Manager, who acknowledged that the policy required water flushes at specific intervals during medication administration via gastric tube.
Failure to Provide Adequate ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident who was unable to perform these tasks independently. The resident, who was admitted with multiple diagnoses including hypertension, cerebrovascular accident, and left-sided hemiparesis, was dependent on staff for personal hygiene needs. Despite the facility's policy to provide necessary care to residents unable to carry out ADLs, the resident's fingernails were significantly overgrown, causing discomfort and pain. The resident had been seeking assistance for nail trimming since November, but the facility's efforts, including referrals to dermatology and podiatry, were unsuccessful in addressing the issue. Observations and interviews revealed that the facility lacked the appropriate equipment to trim the resident's nails due to hand contractures, and the resident only allowed the wound care nurse to attempt trimming. The nurse practitioner and supervising physician explored options such as nail removal, but the resident was not a suitable candidate for surgery due to co-morbidities. Despite prescribing topical treatments, the resident continued to experience pain, and the facility's staff expressed feeling bad for the resident's situation. The deficiency highlights the facility's inability to meet the resident's ADL needs, specifically in managing the resident's nail care effectively.
Medication Administration Error via Enteral Feeding Tube
Penalty
Summary
The facility failed to ensure proper medication administration via enteral feeding tube for a resident, resulting in a medication error rate of 19%. The Licensed Practical Nurse (LPN) involved did not adhere to the facility's policy on administering medications through a gastric tube. Specifically, the LPN did not flush the gastric tube with water before administering medications, between each medication, and after completing the medication administration. This was observed during the administration of five medications, including Lactulose solution, fluoxetine, lorazepam, midodrine, and Nexium, to the resident. The LPN's actions led to the gastric tube becoming clogged during the administration of Nexium, which required manual manipulation to clear. The facility's policy clearly outlines the need for water flushes to prevent such issues, but these steps were not followed. The resident's physician orders also specified a flush of 30 ml of warm water before and after medication administration, which was not adhered to by the LPN. This oversight was confirmed through observation, record review, and staff interviews, highlighting a significant deviation from the established standards of practice for medication administration via enteral feeding tubes.
Failure to Follow PPE Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) adhered to personal protective equipment (PPE) requirements while administering medication via a gastric tube to a resident identified as R66. The facility's policy on Infection Prevention and Control, dated 5/15/23, mandates the use of enhanced barrier precautions (EBP), including gowns and gloves, during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms (MDROs). Despite a sign on the door indicating EBP precautions, the LPN did not wear a gown during the medication administration process. During an interview, the LPN acknowledged forgetting to wear a gown, despite having received training on EBP requirements. The facility's Administrator and Regional Clinical Manager confirmed that EBP had been in effect since 4/1/24 and that the LPN, who works on an as-needed basis, had been trained on these requirements. They also noted that it has been challenging for staff to consistently adhere to these precautions, despite frequent educational efforts by the facility.
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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