Magnolia Manor - Rock Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Hill, South Carolina.
- Location
- 127 Murrah Dr, Rock Hill, South Carolina 29732
- CMS Provider Number
- 425165
- Inspections on file
- 26
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Magnolia Manor - Rock Hill during CMS and state inspections, most recent first.
A Laundry Aide was observed handling soiled linen and clothing without wearing gloves, contrary to facility policy requiring PPE use. The aide collected, tied, and replaced soiled linen bags with bare hands across multiple units, and both the Laundry Manager and Administrator confirmed that gloves should have been worn during these tasks.
A resident with severe cognitive impairment and a history of violent behavior was subjected to physical, verbal, and mental abuse by an LPN. The LPN used inappropriate language and physically hit the resident, escalating the situation. Witnesses confirmed the LPN's actions, and the facility failed to adhere to its policy on abuse prevention.
The facility failed to provide palatable meals as per menu specifications, with surveyors observing bland and freezer-burnt food items. Residents expressed dissatisfaction, noting the food was unappetizing and lacked flavor. The CDM stated no grievances were received and mentioned reliance on frozen items for meals.
The facility failed to ensure proper food storage and handling, with expired and improperly sealed items found in the kitchen. The CDM admitted staff do not check expiration dates, and was observed preparing food without a beard restraint. Additionally, the ice machine was found dirty with a mold-like substance.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of cockroaches in the kitchen area. Cockroaches were seen on the floor near the stove, on a bag of bread, and on the dishwasher. The Kitchen Manager initially claimed it was his first time seeing roaches but later admitted to having seen them before and contacting Ecolab.
A facility failed to follow proper wound care procedures for a resident with a stage 2 pressure ulcer. The resident's wound was not healing as expected, and during an observation, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions, failing to wear a gown and perform hand hygiene after removing the resident's blanket. The nurse admitted to being nervous and unaware of the lapse in procedure.
A facility failed to provide physician-ordered restorative services for a resident with a left-hand contracture. Despite orders for range of motion exercises and splint application, documentation did not show the splint was used, and staff provided inconsistent accounts of care. The resident reported the splint had not been used in months, and it no longer fit. The LPN responsible did not report refusals, and the OT confirmed the splint was not used as intended.
A facility failed to dispose of expired medications and biologicals on one medication cart. An observation revealed expired items, including eye drops and lab-vacutainers. Interviews with an LPN and the Administrator confirmed that staff are responsible for auditing carts daily to ensure expired items are removed and documented.
A resident with a stage 2 pressure wound was not provided proper infection control during wound care. The Wound Care Nurse failed to don a gown as required by Enhanced Barrier Precautions, despite signage indicating the need for PPE. The nurse admitted to forgetting the precautions due to nervousness.
A resident with multiple medical conditions, including dementia and atrial fibrillation, was not properly assessed by an LPN after a CNA reported changes in the resident's condition. The LPN failed to perform a thorough assessment or notify the physician, leading to a delay in care. The resident was later found unresponsive and pronounced dead after emergency services were called. This incident was identified as an Immediate Jeopardy situation due to non-compliance with federal regulations on abuse, neglect, and exploitation.
A resident experienced verbal abuse from an LPN, who made derogatory comments about the resident's bowel movement in front of others. The resident, who was cognitively intact, felt humiliated by the LPN's behavior. The incident was corroborated by the resident's roommate and reported to the Social Services Director.
A long-term care facility failed to protect residents from the misappropriation of medications, including controlled substances and routine medications. One resident missed doses of oxycodone, another had issues with tramadol delivery, and a third missed doses of Ozempic due to medication unavailability. The Assistant Director of Nursing failed to secure narcotic medications properly, leading to their misappropriation, and was subsequently terminated for policy violations.
Failure to Ensure Proper PPE Use During Soiled Linen Handling
Penalty
Summary
Staff failed to follow facility policy regarding the use of personal protective equipment (PPE) when handling soiled linen and clothing. Multiple observations showed a Laundry Aide collecting and handling bags of soiled linen from various units without wearing gloves, despite the facility's policy requiring gloves and gowns to be donned when handling soiled items. The Laundry Aide was seen tying, removing, and replacing soiled linen bags with bare hands, only using hand sanitizer after handling the bags. Interviews with the Laundry Manager and the Laundry Aide confirmed that gloves were not being worn during these tasks, with the Laundry Aide stating that gloves could not be worn and the Laundry Manager acknowledging that gloves were not available in the soiled utility rooms. The Administrator also confirmed that staff are expected to wear gloves when handling soiled linen, both in the utility rooms and laundry room, as per facility policy.
Failure to Protect Resident from Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from physical, verbal, and mental abuse by an LPN. The incident involved the LPN using inappropriate language and physically hitting the resident after the resident hit the LPN. Witnesses observed the LPN's actions, and the State Agency determined that any reasonable person in the same situation would experience adverse psychosocial harm. The resident involved had a history of severe cognitive impairment, traumatic brain injury, schizophrenia, and other conditions that contributed to violent behavior and unsteadiness. Upon returning from the hospital, the resident became belligerent and combative, refusing to get off the stretcher and hitting staff members. The LPN responded by antagonizing the resident, using derogatory language, and physically pushing the resident, which escalated the situation further. The incident was reported to the police, and a police report documented the assault and battery. Interviews with staff and witnesses revealed that the LPN's actions were not isolated, as the LPN continued to belittle and physically engage with the resident, even after the resident had calmed down. The facility's policy on abuse, neglect, and mistreatment was not adhered to, resulting in the failure to protect the resident from harm.
Removal Plan
- Resident resides in the facility without negative effect.
- Medical Director notified of incident. No reported concerns.
- Resident was reviewed and observed for physical and or psychosocial issues, none identified.
- Incident Reported to all three state agencies at time of notification.
- Alleged perpetrator was suspended immediately pending investigation.
- Administrator/Designee interviewed alert and oriented residents and observed non-oriented residents for signs and symptoms of abuse.
- Director of Nursing/Designee completed body audits on interviewed and observed residents.
- A review of the 24-hour report and facility activity report was completed by the Facility Administrator to identify possible allegations of abuse or neglect and to review residents with change of conditions. No concerns identified.
- Facility Staff were re-educated by the Administrator on Abuse, Neglect and Misappropriation policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect. Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.
- Immediate identification and removal of the alleged perpetrator.
- Identification and assessment of the alleged victim.
- Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and Social worker regardless of time of day.
- This reeducation began immediately and was completed. Any staff not receiving this information prior to this date will receive prior to next schedule shift. This education will be presented in New Hire and agency staff orientation.
- Administrator contacted Regional Ombudsman.
- Director of Nursing or ADON will observe care of residents to monitor for forceful and/or aggressive care of residents and will address any identified issue at time of discovery.
- Social Services Director will interview alert and oriented residents randomly to validate that residents feel safe and have no concerns of aggressive treatment.
- The results of this monitoring will be presented to the Quality Assurance/Performance improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery.
- Ad Hoc QAPI was held.
- The Medical Director was notified of the Immediate Jeopardy.
Deficiency in Meal Quality and Preparation
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable and prepared according to menu specifications. During observations by surveyors, test trays revealed that the food items, including sweet mashed potatoes, watery squash, a burnt dinner roll, bland chopped Polish sausage, and Salisbury steak, were either bland, under-seasoned, or tasted freezer burnt. Residents expressed dissatisfaction with the meals during a resident council meeting, stating that the food was not appetizing, lacked flavor, did not look good, and seemed not fresh. The Certified Dietary Manager (CDM) reported not receiving any grievances related to food services and mentioned that the facility primarily uses frozen items for meals, occasionally cooking fresh items for residents.
Deficiencies in Food Storage, Handling, and Sanitation
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the kitchen, as observed during a survey. Several expired food items, including cartons of sweet tea and tomato juice, were found in dry storage, along with moldy apple juice and improperly sealed orange juice, dinner rolls, and hashbrowns. Additionally, an open, undated, and unlabeled bag of unidentified cubed meat was found in the refrigerator. The Certified Dietary Manager (CDM) admitted that staff do not check food deliveries for expiration dates, assuming the items are new, and mentioned that the Vitality juices had just been removed from the freezer. Furthermore, the facility did not ensure that kitchen staff wore appropriate hair and beard restraints during meal preparation. The CDM was observed preparing food without a beard restraint, stating he was busy and had forgotten it. The ice machine was also found to be improperly cleaned, with a black mold-like substance on the inside white panel. The CDM indicated that the maintenance man was responsible for cleaning the ice chest monthly, and claimed it had been cleaned the previous day.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of cockroaches in the kitchen area. During an observation on July 31, 2024, at 10:45 AM, multiple cockroaches were seen crawling on the floor near the stove. Further observations on August 1, 2024, revealed a cockroach crawling on a bag of bread at 10:57 AM and another on the dishwasher at 12:15 PM. The facility's undated pest control policy states that it will maintain an effective program to prevent or eliminate infestations of pests and rodents. During an interview on July 31, 2024, at 11:30 AM, the Kitchen Manager initially stated that he had never seen any roaches before and it was his first time seeing them. However, in a follow-up interview, he admitted to having seen some roaches a while back and mentioned that they had contacted Ecolab to address the issue.
Failure to Follow Proper Wound Care Procedures
Penalty
Summary
The facility failed to ensure proper wound care procedures were followed for a resident with a stage 2 pressure ulcer on the right buttock. The resident, who was admitted with conditions including diabetes mellitus type 2 and a non-pressure chronic ulcer of the buttock, had a pressure wound that was not progressing towards healing. The physician's orders specified cleaning the wound with normal saline solution or wound cleanser, applying honey hydrogel, and covering it with a ZETUVIT silicone border dressing. During an observation, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions as indicated by the signage on the resident's door. The nurse did not wear a gown and failed to perform hand hygiene after removing the resident's blanket, which is against the facility's policy for performing a dressing change. The nurse later admitted to being nervous and unaware of not following the proper procedure.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide physician-ordered restorative services for a resident, identified as R3, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a left-hand contracture. The resident was cognitively intact and did not exhibit behaviors of care rejection. The physician's orders and care plan specified that R3 should receive range of motion exercises and have a left-hand splint applied for 6.5 hours three times a week. However, documentation from the facility did not show evidence of the splint being applied, nor were there any documented refusals from the resident. Interviews and observations revealed that the splint was not being used as ordered. R3 reported that the splint had not been used in months, and it no longer fit due to lack of regular use. Staff members, including an LPN and CNAs, provided inconsistent accounts regarding the application of the splint and the documentation of care. The LPN responsible for the restorative therapy program admitted to not reporting refusals and not witnessing any refusals from R3. The occupational therapist confirmed that the splint was intended to prevent further contracture and was not being used as intended.
Expired Medications and Biologicals Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications and biologicals on one of its medication carts, specifically Medication Cart B located on Hall 200. During an observation, it was found that the cart contained expired items, including two Systane Complete Eye drops with an expiration date of March 20, 2024, two Lab-vacutainers with an expiration date of February 28, 2023, and two Urine C&S with an expiration date of April 30, 2023. This indicates a lapse in the facility's adherence to its policy, which mandates the immediate removal and proper disposal of outdated, contaminated, or deteriorated medications and biologicals. Interviews conducted with the Licensed Practical Nurse (LPN) and the Administrator revealed that the facility's protocol requires all nursing staff to audit their medication carts daily to ensure no expired medications are present. The LPN confirmed the presence of expired items and acknowledged the responsibility of nursing staff to discharge and document expired medications. The Administrator reiterated that expired medications should be disposed of and documented as per the facility's policy, emphasizing the responsibility of nursing staff to check their carts daily for expired items.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control procedures during wound care for a resident, identified as R26, who was on Enhanced Barrier Precautions (EBP) due to a stage 2 pressure wound on the right buttock. The facility's policy, last revised on 05/15/23, mandates the use of personal protective equipment (PPE) such as gloves and gowns for residents with wounds, regardless of MDRO colonization status. During an observation, the Wound Care Nurse (WCN) did not don a gown before performing wound care on R26, despite the signage indicating EBP requirements. R26 was admitted with diagnoses including diabetes mellitus type 2, depression, and a non-pressure chronic ulcer of the buttock. A progress note from 07/25/24 indicated that the wound was not healing as expected, with an increase in surface area and moderate serous exudate. The WCN acknowledged awareness of the EBP but admitted to not applying the PPE due to nervousness and forgetting the precautions. This oversight in following the infection control protocol led to the deficiency noted in the report.
Failure to Provide Timely Care and Assessment for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to ensure the quality of life for a resident, identified as R1, who had multiple medical conditions including dementia, altered mental status, and atrial fibrillation. R1 was admitted with a Full Code status, indicating that resuscitation efforts should be made in the event of a cardiac or respiratory arrest. On the day of the incident, a Certified Nursing Assistant (CNA) noticed that R1's breathing had slowed and that he was not responding as usual. The CNA notified the Licensed Practical Nurse (LPN), who briefly checked on R1 but did not perform a thorough assessment or notify the physician. Approximately 20 minutes later, the CNA found R1 unresponsive and not breathing. Emergency services were called, and CPR was initiated, but R1 was pronounced dead shortly after. Interviews with staff revealed that there was a lack of timely and appropriate response to R1's change in condition. The LPN admitted to not providing care until R1 was unresponsive and failed to document the incident or notify the physician as required by the facility's policy. The facility's policy on abuse, neglect, and change in condition emphasizes the importance of timely assessment and communication with medical staff. However, in this case, the LPN did not adhere to these guidelines, resulting in a failure to provide necessary care to R1. The incident was identified as an Immediate Jeopardy situation, indicating a serious threat to the health and safety of residents, and was related to non-compliance with federal regulations regarding freedom from abuse, neglect, and exploitation.
Removal Plan
- A review of the 24-hour report and facility activity report was completed by the Facility Administrator to identify possible allegations of abuse or neglect and to review residents with change of conditions.
- Facility Staff were re-educated by the Administrator on Abuse, Neglect and Misappropriation policy.
- Facility Administrator/Interim DON will re-educate licensed staff on Change of Condition.
- Administrator contacted Regional Ombudsman.
- The Director of Nursing/Designee will review the 24-hour report and the Facility Activity report to identify any documentation regarding a change of condition, abuse and validate that the resident has been assessed appropriately, physician notified, responsible party notified, and orders implemented properly. This includes diagnostic testing and results.
- The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery.
- Ad Hoc QAPl was held.
- The Medical Director was notified of the Immediate Jeopardy.
Verbal Abuse Incident Involving LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by an LPN, as evidenced by multiple interviews and record reviews. The incident involved a resident who was cognitively intact, with a BIMS score of 14 out of 15, and had medical conditions including generalized anxiety disorder and a stage 3 pressure ulcer. The resident was subjected to derogatory comments by the LPN regarding a bowel movement incident. The LPN referred to the resident in a demeaning manner, calling her 'Stinky' and making comments about the smell in front of the resident's roommate and others. The resident expressed feeling humiliated by the LPN's behavior, which included loud and rude remarks about the smell and asking the roommate if a mask was needed. The roommate corroborated the resident's account, noting the LPN's loud and inappropriate comments. The Social Services Director also confirmed that the resident reported the LPN's derogatory remarks. The Director of Nursing and the Administrator, both new to their positions, were unable to provide information regarding the abuse allegation.
Misappropriation of Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically controlled substances and routine medications. The facility's policy on abuse, neglect, exploitation, or mistreatment prohibits the misappropriation of a resident's property and/or funds. However, the facility did not adhere to its policy regarding the receipt and handling of controlled substances, which requires a licensed nurse to verify the contents and quantity of medications upon delivery and to secure them immediately in a locked compartment. One resident, who was admitted with diagnoses including spinal stenosis and pressure ulcers, did not receive scheduled doses of oxycodone due to the medication being on hold. Another resident, with chronic pain and other conditions, had issues with tramadol delivery, which required a signature for refill and was temporarily pulled from an emergency kit. A third resident, with diabetes and obesity, missed doses of Ozempic because the medication was not available, and attempts to obtain an early refill were denied by insurance. Interviews revealed that the Assistant Director of Nursing (ADON) signed for the delivery of narcotic medications but failed to secure them properly, leading to their misappropriation. The Director of Nursing (DON) confirmed the misappropriation of medications for the three residents. The ADON was terminated for violating facility policy, and the facility administrator attempted to address the missing medications with the pharmacy, but insurance issues prevented timely replacement.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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