Martha Franks Baptist Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laurens, South Carolina.
- Location
- One Martha Franks Drive, Laurens, South Carolina 29360
- CMS Provider Number
- 425334
- Inspections on file
- 15
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Martha Franks Baptist Retirement Center during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and depression, who was usually independent with toileting, became involved in an altercation with a CNA while the CNA was assisting with cleaning a soiled bathroom. The resident became agitated, spit on the CNA, and struck the CNA in the face with a BM-soiled washcloth. In retaliation, the CNA held the resident’s hands and struck the resident in the face with an open hand, later describing the action as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff and law enforcement that she had put her hands on and slapped the resident. Staff assessments noted the resident was visibly upset but without visible injuries, and the resident could not recall the incident due to severe cognitive impairment. Surveyors determined this constituted non-compliance with abuse regulations and cited the facility for failure to ensure freedom from physical abuse.
Surveyors found that dietary staff did not consistently label or discard expired food items, including unlabeled shredded cheese, sundried tomatoes, carrots, coleslaw mix, spinach, and croutons. These items were not stored according to facility policy, which requires proper labeling, dating, and stock rotation. The CDM and Administrator confirmed that staff are responsible for these tasks and that expectations were not met.
A Laundry Aide failed to follow infection control protocols by not properly removing PPE or performing hand hygiene after handling soiled linens, and by placing contaminated items in a clean area, resulting in cross-contamination between soiled and clean laundry areas.
The facility failed to maintain cleanliness and proper food handling standards, with debris found on the kitchen floor and improper hair restraint by staff. Food items were not labeled or dated, and expired items were not discarded, posing potential health risks to residents. Personal items were also improperly stored in the nourishment room.
A resident's MDS assessment failed to accurately reflect their fall status, despite documented incidents and interviews confirming two falls. The facility's policy requires accurate assessments, but the MDS Coordinator did not code the falls, leading to a deficiency in the assessment process.
A resident with severe cognitive impairment and a history of Alzheimer's disease and dementia was observed wandering aimlessly and into other residents' rooms. Despite documentation of this behavior in progress notes, the facility failed to implement a care plan to address the wandering. Interviews with staff confirmed the lack of a care plan, which was required by the facility's policy.
A resident with severe cognitive impairment and diabetes did not receive proper nail care, as observed over several days. Despite facility policies requiring regular nail maintenance, the resident's nails were found untrimmed and dirty. Staff interviews revealed a lack of communication and adherence to care protocols, with CNAs failing to notify nurses about the need for nail care, especially given the resident's diabetic condition.
A facility failed to ensure staff wore appropriate PPE for a resident on enhanced barrier precautions (EBP) due to an indwelling urinary catheter. During a shower, a CNA wore only gloves, not a gown, contrary to the facility's EBP policy. The resident had a history of urinary issues and required EBP, as noted in their care plan and order history. Interviews confirmed the expectation for staff to follow the EBP policy.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident from physical abuse by a CNA. The facility’s abuse policy defines physical abuse as including hitting, slapping, and controlling behavior through corporal punishment. The resident involved was admitted with major depressive disorder and dementia with agitation, and a recent MDS showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident was generally independent with toileting and transfers. On the day of the incident, the resident was on a locked dementia unit and had experienced bowel incontinence, leaving the bathroom soiled. A CNA entered the resident’s room to assist with cleaning the bathroom. During this interaction, the resident became agitated and combative, reportedly spitting on the CNA and striking the CNA in the face with a wet washcloth containing bowel movement. The CNA later reported that she responded by holding the resident’s hands above her head and then making contact with the resident’s face with an open hand, described as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff, including the charge nurse, DON, Administrator, and Social Services, that she had put her hands on the resident and struck the resident in the face with an open hand in retaliation for the resident’s actions. A police report documented that the CNA admitted to assaulting the resident with an open-hand slap during a physical altercation. Staff who assessed the resident after the incident noted that the resident appeared visibly upset but had no visible injuries, and the resident was unable to recall the specific events due to severe cognitive impairment. The State Agency determined that the facility’s non-compliance with abuse regulations caused or was likely to cause serious harm and cited the facility under 42 CFR 483.12 for failure to ensure the resident was free from physical abuse.
Removal Plan
- Removed CNA3 from the resident care area after the incident.
- Interviewed CNA3 regarding the incident.
- Terminated CNA3 by the Administrator and DON.
- Notified law enforcement of the incident.
- Submitted a report to the Regional Ombudsman.
- Completed a nursing assessment and body audit of R1; no injuries found.
- Notified R1's family/responsible party of the incident.
- Monitored residents for psychosocial distress or changes by nursing staff and Social Services.
- Provided 1:1 re-education for staff working in skilled nursing on abuse and appropriate response/intervention and workplace fatigue.
- Conducted an investigation and determined there was no physical evidence of abuse.
- Social worker interviewed all residents on Unit 3 regarding abuse, whether any abuse had been witnessed/experienced, and whether residents felt safe.
- Social worker interviewed residents on other skilled units regarding abuse and whether residents felt safe.
- Arranged for MD and PA to evaluate R1; MD issued new medication orders and PA checked on the resident.
- Obtained family consent for a psychiatric evaluation.
- Social worker contacted the family and obtained updates; family visited and reported no changes in mood/behavior/psychosocial status.
- Social worker checked in on R1 and monitored for changes.
- Initiated in-house education for all staff working in Skilled Nursing on types/definitions of abuse, dementia with abuse prevention, de-escalation of behaviors, and how to appropriately avoid these situations.
- Re-educated staff on who the Abuse Coordinator is and how to notify the Abuse Coordinator of concerns.
- Reviewed the abuse policy with staff.
- Obtained statements from all staff who work in Skilled Nursing.
- Continued education ongoing.
- Nursing management (DON, ADON, Unit Managers) to conduct rounding and audits for signs of abuse.
- Held QAPI and updated it regarding this issue.
Failure to Properly Label and Discard Expired Food Items
Penalty
Summary
The facility failed to properly label and discard expired food items in the main kitchen, as observed during a survey. In the main cooler, there was a 1-gallon Ziplock bag of shredded cheese not in its original packaging, unlabeled, and marked with a date of 9/17. Additionally, a 5-lb bag of sundried tomatoes was opened with no open date, two 5-lb bags of shredded carrots had a use-by date of 09/04/2025, and six 5-lb bags of coleslaw mix had a use-by date of 08/25/2025. In the salad/bar cooler, a metal pan of spinach was covered but not labeled, and a 1-gallon bag of shredded cheese was present with no label. In the dry storage closet, a Ziplock bag of croutons was not in its original packaging and not labeled. All these findings were confirmed by the Certified Dietary Manager (CDM) and the CDM in Training. Interviews with the CDM revealed that all dietary staff are responsible for inspecting food storage areas and ensuring leftover items are properly labeled and stored, with monthly in-service training on food safety practices. The CDM stated that leftovers are stored for no more than three days. The Administrator confirmed expectations that all food items should be free from expiration and properly labeled and dated. The facility's policy requires stock rotation, proper labeling, and dating of food items, but these procedures were not consistently followed, resulting in the observed deficiencies.
Improper Handling and Transport of Soiled Linens by Laundry Staff
Penalty
Summary
The facility failed to ensure proper handling and transport of resident linens in accordance with its infection prevention and control policies. During observation, a Laundry Aide (LA) was seen retrieving dirty laundry from the soiled utility room without properly doffing her washable blue gown and gloves or completing hand hygiene due to a lack of paper towels. The LA then walked through hallways and into the laundry room still wearing the soiled PPE. Additionally, the LA was observed folding and placing a soiled blue gown under the laundry table in the clean area of the laundry room, where disposable PPE was also found, indicating cross-contamination between soiled and clean areas. Interviews with the Housekeeping Supervisor and Maintenance/Environmental Director confirmed that the LA did not follow established procedures, which require donning disposable gowns and gloves, doffing them after handling soiled laundry, and performing hand hygiene. The Housekeeping Supervisor acknowledged the cross-contamination and stated that all laundry staff had previously received education on proper procedures. Despite ongoing education efforts, the improper handling and transport of soiled linens by the LA was observed, in direct violation of facility policy.
Deficiencies in Kitchen Cleanliness and Food Handling
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling standards in the kitchen and nourishment rooms, which could potentially affect all residents receiving food from the kitchen. Observations revealed debris on the kitchen floor, including a sugar substitute packet, mayonnaise packet, and a dirty wet towel near the freezer entrance. Additionally, a cart near the refrigerator was found with dirt and a dried yellow stain. The Director of Food Services acknowledged these issues, and the Director of Nursing confirmed that the kitchen should be kept clean, swept, and mopped. Furthermore, a dietary aide was observed with hair hanging out of a hat, which was not compliant with the facility's policy requiring hairnets for kitchen staff. The facility also failed to ensure food items were properly labeled and dated, and expired items were discarded. Observations in various storage areas revealed undated containers of rice, pasta, and other food items, as well as expired milk cartons. The Director of Food Services and the Dietary Manager acknowledged these deficiencies, noting that the absence of labeling and dating could lead to residents consuming expired food, potentially causing illness. Personal items, such as a hairbrush and nail polish remover, were also found in the nourishment room, which the Administrator and Director of Nursing confirmed should not have been there.
Inaccurate MDS Assessment of Resident's Fall Status
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment accurately reflected the fall status of a resident, identified as R31, among 22 sampled residents. The deficiency was identified through observation, interviews, record reviews, and policy reviews. The facility's policy on resident assessments, revised in March 2022, mandates that the resident assessment coordinator ensures timely and appropriate assessments. However, the MDS for R31, with an Assessment Reference Date (ARD) of May 24, 2024, incorrectly indicated that the resident had no falls since admission or the last assessment. This was despite the resident having experienced two falls, one in the dining room and another in their bathroom, as documented in event reports and confirmed by the resident during interviews. R31, who was admitted to the facility in August 2021, had a medical history of Alzheimer's disease, muscle weakness, and lack of coordination, and was identified as being at risk for falls. The resident's care plan, initiated in February 2022, acknowledged this risk. Interviews with the MDS Coordinator and the Director of Nursing revealed that the MDS should have been coded to reflect the two falls. The Administrator also confirmed that the falls should have been included in the MDS. The failure to accurately document the resident's fall status on the MDS represents a deficiency in the facility's assessment process.
Failure to Develop Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to develop a care plan to address the wandering behavior of a resident with severe cognitive impairment. The resident, who was admitted with a medical history including Alzheimer's disease and dementia, was observed wandering aimlessly around the unit and into other residents' rooms. Despite multiple entries in the resident's progress notes documenting this behavior, no care plan was implemented to address the wandering. Interviews with facility staff, including a CNA, RN, MDS Coordinator, and the Director of Nursing, confirmed the resident's wandering behavior and the lack of a care plan. The MDS Coordinator acknowledged that the resident should have had a care plan in place, and the Director of Nursing stated that a care plan should have been implemented as soon as the wandering behavior was observed. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, which were not developed for this resident.
Failure to Provide Adequate Nail Care to a Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, identified as R26, who was reviewed for activities of daily living (ADL). The resident, who had a medical history of Alzheimer's disease, diabetes mellitus, and dementia with behavioral disturbance, was admitted to the facility in May 2018. The resident's care plan, initiated in January 2022, required assistance with ADLs due to cognitive impairment and other health issues, including the provision of fingernail care. However, observations on multiple occasions revealed that R26 had untrimmed and dirty fingernails with dark debris underneath, indicating a lack of proper nail care. Interviews with facility staff, including CNAs and an LPN, confirmed that nail care was not performed as expected. CNA1 and CNA2 acknowledged that nail care should be checked daily, especially during showers, but admitted that they did not notify the nurse when nail care was not completed. CNA2 specifically mentioned that due to the resident's diabetic condition, CNAs were not permitted to cut nails, and this task should be performed by a nurse. The LPN and the Director of Nursing both stated that nail care should have been part of the resident's shower routine, and the Administrator emphasized that CNAs should report to the nurse if nail care was not completed. Despite these expectations, the deficiency in nail care for R26 was evident, as the resident's nails remained uncleaned and untrimmed over several days of observation.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to the infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). The facility's policy required staff to wear gloves and gowns during high-contact resident care activities for residents with indwelling medical devices, such as urinary catheters. However, during an observation, a Certified Nurse Assistant (CNA) was seen providing a shower to a resident with an indwelling urinary catheter while only wearing gloves and not a gown, as required by the facility's EBP policy. The resident involved had a medical history that included urinary tract infection, retention of urine, obstructive and reflux uropathy, bladder neck obstruction, and the presence of urogenital implants. The resident's care plan and order history indicated the need for EBP due to the indwelling urinary catheter, with specific instructions for staff to wear gloves and gowns during high-contact activities. Interviews with the CNA, the Director of Nursing (DON), and the Administrator confirmed the expectation for staff to follow the EBP policy, which was not adhered to in this instance.
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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