Oak View Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Conway, South Carolina.
- Location
- 3300 4th Avenue, Conway, South Carolina 29527
- CMS Provider Number
- 425121
- Inspections on file
- 25
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oak View Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to properly store food and ensure proper sanitization in the kitchen. Observations revealed improperly stored and unlabeled food items in dry storage, the freezer, and the refrigerator. Additionally, the dishwasher was not receiving sanitizer, and the three-compartment sink was not used correctly, posing a risk of cross-contamination. Staff interviews indicated inconsistent practices and a lack of awareness regarding proper sanitization procedures.
A resident's code status was inaccurately documented in their medical record, leading to a deficiency. Despite the resident's expressed wish for DNR status, their EMR indicated Full Code, conflicting with a signed DNR order. Interviews with staff revealed inconsistencies in verifying code status, and the DON confirmed the discrepancies.
A resident with severe cognitive deficits and high fall risk sustained a femur fracture after being found on the floor. Despite visible swelling and pain, the resident was not immediately sent to the hospital. Instead, Tylenol was administered, and an x-ray was delayed, resulting in prolonged suffering. Interviews revealed a lack of urgency in addressing the injury, and the resident was eventually sent to the hospital hours later, where the fracture was confirmed.
A resident with a stage 4 pressure ulcer on the right heel developed maggots in the wound due to improper management by the facility. Despite the facility's policy to prevent infections, staff failed to communicate effectively and take immediate action, resulting in the resident being sent to the hospital for evaluation.
The facility failed to remove expired medications from storage and medication carts, as observed in 5 of 6 carts and 2 of 4 medication rooms. Expired medications, including insulin pens and various tablets, were confirmed by staff. Interviews revealed inconsistent checking of expiration dates, and the DON acknowledged issues with receiving expired medications from the pharmacy.
The facility failed to employ a certified dietary manager as required, with the acting CDM currently enrolled in a certification program expected to be completed by April 2025. The part-time RD expressed concerns about food safety due to the lack of certification and suggested employing a contract interim CDM until certification is achieved.
The facility failed to employ a qualified, full-time social worker as required for a facility with more than 120 beds. The current Social Worker Interim/Designee lacks a license or certification and also serves as the Central Supply Coordinator. The facility's administrator confirmed the absence of a licensed social worker, and multiple residents reported the lack of a social worker for some time. A Unit Manager, who does not have a social work degree, has been assisting the interim social worker due to staff turnover.
The facility failed to ensure residents had access to their personal funds, affecting four residents with varying cognitive abilities. Despite the facility's policy, residents reported being unable to access funds on weekends. The administrator admitted the receptionist responsible for fund distribution was not trained, leading to residents being unaware or unable to access their funds.
A facility failed to involve a resident with severe cognitive impairment and their representative in care planning. The representative was not contacted about the care plan, and both were unaware of its existence. Facility staff could not provide proof that the resident or representative was informed of the scheduled care plan meeting.
A resident with multiple diagnoses, including Alzheimer's disease, did not receive prescribed heel and ankle protection devices and a wedge cushion while in bed, as per physician orders. Observations showed the resident without these devices, and staff interviews revealed a lack of awareness and availability of the required items. The DON emphasized the importance of following physician orders.
A resident was receiving oxygen without a physician's order, contrary to the facility's policy requiring such orders. The resident, who had moderate cognitive impairment, was observed receiving oxygen at 3 LPM via nasal cannula. A nurse confirmed the absence of an active order for oxygen, noting that even in acute situations, an order should be obtained.
The facility failed to maintain consistent RN coverage for 8 consecutive hours daily, as required by regulation. Staffing sheets revealed missing RN coverage on specific dates, confirmed by staff interviews. Despite efforts to cover shifts using agency staff and internal adjustments, the facility could not provide documentation for the missing dates, leading to a deficiency finding.
A facility failed to ensure staff used appropriate PPE for a resident on Enhanced Barrier Precautions. Despite the policy requiring PPE for high-contact care activities, CNAs were observed entering the resident's room without donning PPE. The resident, with multiple medical conditions and a PEG tube, required such precautions. Staff interviews revealed lapses in compliance, with CNAs admitting to forgetting PPE, and the DON acknowledged the need for proper PPE use and ongoing education efforts.
The facility failed to maintain a sanitary environment in the Unit 4 shower room/toilet area, with a stained toilet and poor lighting observed. The housekeeper lacked access to the area, and the housekeeping supervisor was unaware of the issues. The maintenance supervisor was also uninformed about the inoperable toilet and poor lighting, as no maintenance request was submitted.
Improper Food Storage and Sanitization in Kitchen
Penalty
Summary
The facility failed to properly store food in the kitchen, as observed during an initial tour. Several items in dry storage were found improperly stored, including cases of corn and cans of soup that were dented and not labeled. In the freezer, multiple bags and boxes of food items were unidentified, unlabeled, and undated. The refrigerator contained items such as sweet potatoes with a white fuzzy substance, indicating spoilage, and other food items that were not labeled or dated. These observations indicate a lack of adherence to the facility's policies on food storage, which require all foods to be covered, labeled, and dated. Additionally, the facility failed to ensure proper sanitization in the three-compartment sink and the dishwasher. During an observation, it was noted that the dishwasher was not receiving sanitizer, and the temperature was below the required level for effective sanitization. The three-compartment sink was not being used correctly, as the sanitizing compartment was empty, and staff were not consistently using all three compartments for washing dishes. Interviews with kitchen staff revealed a lack of awareness and inconsistent practices regarding the use of sanitizer and proper dishwashing procedures. The facility's non-compliance with federal health, safety, and quality regulations was determined to have caused or was likely to cause serious harm, leading to an Immediate Jeopardy citation. The deficiency was related to the failure to use sanitizer in the three-compartment sink and dishwasher, which posed a risk of cross-contamination and potential foodborne illness among residents. The facility's policies on dishwashing and sanitization were not being followed, contributing to the deficiency.
Removal Plan
- Sanitizer for dishwasher and 3-compartment sink was properly installed by Dietary Resource.
- All dishes, pots, pans, and utensils were washed and sanitized due to the alleged deficient practice by dietary staff after education was provided by Dietary Resource.
- Every shift monitoring for signs and symptoms of foodborne illness due to potential cross-contamination was placed on all residents who take food and/or drink by mouth was entered by Unit Manager and Clinical Resource.
- All dietary staff currently working were educated by Dietary Resource on proper use of sanitizer for dishwasher and 3-compartment sink.
- All dietary staff will receive education on proper use of sanitizer for dishwasher and 3-compartment sink prior to the start of their next shift.
- Education will be included as part of the annual skills fair and new hire orientation for all kitchen staff.
- An adhoc QAPI meeting regarding the items in the IJ template completed. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.
- Daily audit of sanitizer detergent for proper hook up and function to dishwasher and 3-compartment sink and monitored by Dietary Manager or Designee.
- Daily audit of dishwasher to ensure the machine is functioning at manufacturer recommendations and specifications to included temperature monitoring.
- Dietary Manager or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in their medical record, leading to a deficiency. The resident, who had a moderate level of cognitive function, expressed a desire not to be resuscitated, stating, "I want to die, I don't want them to save me." Despite this, the resident's electronic medical record (EMR) indicated a Full Code status, conflicting with a paper Do Not Resuscitate (DNR) order signed by the resident's responsible party and a physician. Additionally, a physician's order for DNR was present in the EMR, but the care plan still reflected a Full Code status. Interviews with facility staff, including LPNs, RNs, and the Director of Nursing (DON), revealed inconsistencies in how code status was verified and documented. Staff members indicated they would check the EMR to verify code status, but the EMR showed conflicting information. The DON confirmed the discrepancies in the resident's code status and acknowledged the need to investigate further. This failure to accurately document and communicate the resident's advance directives led to the identification of Immediate Jeopardy at F578.
Removal Plan
- Resident #424 preferred level intensity was reviewed with responsible party and order was corrected in point click care (PCC).
- The Medical Director was notified of the IJ.
- A full house audit of current residents was reviewed by the Director of Nursing and validated that preferred level of intensity and signed DNR order matches the order in PCC and care plan. No other residents were identified to be affected by the alleged deficiency.
- An in-service was prepared by the DON and initiated by the Assistant Director of Nursing (RN) for all licensed nurses, medical records personnel, and social services employees. The in-service included the advanced directives policy and how to transcribe orders correctly.
- Education will be included as part of the annual skills fair and new hire orientation for licensed nurses, medical records personnel, and social services employees.
- An ad hoc meeting regarding the items in the IJ template completed. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.
- Changes in advanced directives will be reviewed daily clinical meeting 5x a week x12 weeks and monitored by Director of Nursing or Designee.
- DON or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.
Neglect Leads to Delayed Treatment of Resident's Fracture
Penalty
Summary
The facility failed to ensure that a resident, identified as R170, was free from neglect, resulting in a serious injury that was not promptly addressed. R170, who had severe cognitive deficits and was at high risk for falls, sustained a femur fracture after being found on the floor by a CNA. Despite the resident's evident pain and the visible swelling and deformity of the leg, the resident was not immediately sent to the hospital for evaluation and treatment. Instead, the resident was given Tylenol for pain and an x-ray was ordered, which delayed appropriate medical intervention. The progress notes indicate that the resident was found on the floor at 6:45 AM, but there was no documentation of the exact time of the fall. The resident was assessed by a nurse, and a STAT x-ray was ordered, but the x-ray was not performed until several hours later. During this time, the resident remained in pain, and the facility staff failed to take immediate action to send the resident to the hospital, despite the severity of the injury and the resident's condition. Interviews with facility staff revealed that there was a lack of urgency in addressing the resident's injury. The attending physician expected the nursing staff to send the resident to the hospital immediately if there was any indication of an injury from a fall. However, the resident remained in the facility for several hours before being transported to the hospital, where the fracture was confirmed, and the resident was eventually placed in hospice care. This delay in treatment resulted in prolonged pain and suffering for the resident.
Removal Plan
- R170 was assessed by LPN. Provider was notified of findings and STAT x-rays were ordered.
- Tylenol was administered for pain by LPN.
- Follow up Tylenol administration was documented as Resident resting with eyes closed. No facial grimacing noted.
- STAT x-ray results were reported by Trident Mobile.
- Order was received to send R170 to emergency room for evaluation of fracture.
- R170 was assessed by Dr. at Conway Medical Center emergency room.
- The Medical Director was notified of the IJ.
- Residents who had a fall in the past 24 hours were reviewed. One resident was identified. Resident was assessed by Registered Nurse with no signs of pain noted.
- All licensed nurses currently working were educated by Director of Nursing Services about pain management.
- All certified nurse aides currently working were educated by Unit Manager (Registered Nurse) on the process of reporting pain to the licensed nurse on duty.
- All licensed nurses will receive education on pain management prior to the start of their next shift.
- All certified nurse aides will receive education on the process of reporting pain to the licensed nurse on duty prior to the start of their next shift.
- Education will be included as part of the annual skills fair and new hire orientation for all nursing staff.
- An adhoc QAPI meeting regarding the items in the IJ template completed. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.
- The Clinical Interdisciplinary Team will review falls, including pain, 5 days a week in Morning Clinical Meeting.
- Findings will be reported to QAPI committee monthly with additional follow-up and recommendations as needed until substantial compliance is achieved and maintained.
Failure to Manage Wound Leads to Maggot Infestation
Penalty
Summary
The facility failed to properly manage a resident's wound, resulting in the presence of maggots in the wound bed on the resident's right heel. The resident, who was admitted with a stage 4 pressure ulcer on the right heel, osteomyelitis, and a methicillin-resistant staphylococcus aureus infection, was found to have maggots in the wound on October 3, 2024. The facility's policy required that wounds be managed to prevent signs of infection unless unavoidable due to the resident's clinical condition. However, the wound care provided did not prevent the infestation. Interviews with staff revealed a lack of awareness and communication regarding the resident's wound condition. LPN6 was informed of the maggots by the day shift nurse and took action to notify the DON and the physician, resulting in the resident being sent to the emergency room. LPN7, who discovered the maggots during a dressing change, was instructed by RN3 to treat the wound with Dakin's solution and dress it, but there was no Dakin's available at the time. The ADON and RN3 were involved in the communication but did not take immediate action to address the maggots. The facility's failure to manage the wound properly and the lack of immediate and effective communication among staff members contributed to the deficiency. The resident's condition was not adequately monitored, and the presence of maggots was not addressed promptly, leading to the resident being sent to the hospital for further evaluation. The incident highlights a breakdown in the facility's wound care management and communication processes.
Removal Plan
- R103 was found to be affected by the alleged deficient practice.
- LPN received report on R103. LPN notified physician of findings. Order was received to send resident to emergency room for evaluation. EMS was called and resident left the facility with EMS.
- Director of Nursing Services reviewed R103 TAR (treatment administration record). Treatment administered per order.
- An audit of all wounds was completed by Assistant Director of Nursing (RN) and Unit Manager (RN). No changes were noted to any of the wounds.
- All direct care licensed nurses received wound care education.
- Maintenance director completed facility wide observation for pests, insects, or any related issues. No issues were identified.
- Maintenance director contacted Terminix and requested an additional preventative visit and facility administrator ordered air curtain fans for all high traffic doors.
- The Medical Director was notified of the IJ.
- An adhoc QAPI meeting regarding the items in the IJ template completed. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions.
- Wound care education is included as part of the annual skills fair and new hire orientation for all licensed nurses.
- Maintenance Director completed weekly audits of facility for presence of insects, pests, or any other related issues.
- Registered nurses on nursing management team completed weekly audits of wounds for any changes in condition.
- Findings were reported to QAPI committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.
Expired Medications Found in Storage and Carts
Penalty
Summary
The facility failed to ensure expired medications were removed and not stored with other medications in use for residents. This deficiency was observed in 5 of 6 medication carts and 2 of 4 medication rooms. The facility's policy on medication access and storage, as well as administering medications, requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, during observations and interviews, it was found that expired medications, including blood collection tubes, IV catheters, insulin pens, and various tablets, were still present in the medication storage rooms and carts. During the survey, it was noted that several medications, such as Ceftriaxone IV bags, insulin pens, and various tablets, were expired and still stored in the medication rooms and carts. Unit Managers and Licensed Practical Nurses confirmed the presence of these expired medications. Additionally, some medications belonging to individual residents were improperly stored with stock medications, and certain medications were not stored according to the instructions on their labels, such as requiring refrigeration after opening. Interviews with nursing staff revealed a lack of consistent checking of expiration dates before administering medications. The Director of Nursing acknowledged issues with receiving medications from the pharmacy after their expiration dates and stated that discussions had been held with the pharmacy regarding this issue. Despite these discussions, the expectation remains that medications should be administered according to the seven rights of medication administration, which includes ensuring medications are not expired.
Facility Lacks Certified Dietary Manager
Penalty
Summary
The facility failed to employ a certified dietary manager, as required by their policy and regulatory guidelines. The facility's policy, approved on 11/21/22, mandates that if a qualified dietician or other clinically qualified nutrition professional is not employed full-time, a designated director of food and nutrition services must meet specific certification requirements. However, the acting Certified Dietary Manager (CDM) is currently not certified and is only enrolled in a course to become certified by April 2025. This situation has led to concerns about food safety, as expressed by the part-time Registered Dietician (RD), who works only 8 hours per week and is not involved in daily operations. The RD has voiced concerns regarding the lack of certification of the acting CDM and has suggested the facility employ a contract interim travel CDM to provide coverage until the acting CDM becomes certified. Despite these concerns, the acting CDM is still in the process of completing an online program to achieve certification, which is expected to be completed by March or April 2025. This deficiency highlights the facility's failure to comply with staffing requirements for dietary services, potentially impacting the quality and safety of food and nutrition services provided to residents.
Failure to Employ Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified, full-time social worker as required by regulation for a facility with more than 120 beds. The Social Worker Interim/Designee (SWI) confirmed during an interview that she does not have a license or social worker certification and has been working in the position for approximately one month. She also holds the position of Central Supply Coordinator. The SWI had previously held the position of Social Worker Designee for several months in the previous year. The facility's administrator confirmed the absence of a licensed social worker and stated that the facility is in the process of hiring one. During a Resident Council Meeting, multiple residents expressed that the facility has not had a licensed social worker for some time. Additionally, a Unit Manager (UM) confirmed that she does not have a social work degree and has been assisting the SWI intermittently due to the turnover of social workers in the past year.
Failure to Provide Residents Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents who authorized the facility to manage their personal funds had ready and reasonable access to those funds. This deficiency affected four residents, each with varying degrees of cognitive impairment or intactness. The facility's policy stated that residents could manage their funds or withdraw their request for the facility to manage them at any time. However, interviews revealed that residents were unable to access their funds on weekends, contrary to the facility's policy. Interviews with the residents indicated that they were either unaware of their ability to request funds or were told they had no money available. The administrator initially stated that funds were accessible on weekends, but later admitted that the receptionist, who was responsible for distributing funds, had not been trained on handling personal funds. This lack of training and communication led to residents being unable to access their funds as needed, particularly on weekends.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was invited to and allowed to participate in care plan meetings. The facility's policy mandates that residents be informed and involved in care planning, with meetings scheduled at convenient times and signatures obtained post-discussion. However, for a resident with severe cognitive impairment, neither the resident nor their representative was present during a care plan meeting. The facility document indicated that the resident refused to participate, and the representative attended via phone, but the representative later stated that no discussion of the care plan was offered. The resident's representative reported not being contacted about the care plan, and both the resident and representative were unaware of the care plan's existence or purpose. Interviews with facility staff revealed that invitations to care plan meetings are typically printed or mailed, but there was no proof that the resident or representative was informed of the scheduled meeting. This lack of communication and involvement in the care planning process led to the deficiency identified by the surveyors.
Failure to Implement Physician Orders for Resident Care
Penalty
Summary
The facility failed to provide care and services according to physician orders for a resident, specifically regarding the use of heel and ankle protection devices and a wedge cushion while in bed. The resident, who was admitted with multiple diagnoses including Alzheimer's disease and chronic kidney disease, had physician orders for bilateral heel boots and a wedge cushion to be used every shift. However, observations on two separate occasions revealed that the resident was lying in bed without the prescribed heel boots and wedge cushion. Interviews with facility staff, including a CNA and an RN, revealed that the heel boots were not available because they could not be found, and the CNA was unaware of the wedge cushion order. The Director of Nursing stated that staff are expected to follow physician orders and notify the physician and herself if orders cannot be followed. This deficiency highlights a failure in ensuring that physician orders are implemented as prescribed, potentially impacting the resident's care.
Lack of Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician order was in place for the use of oxygen for a resident, identified as R219. The facility's policy on oxygen administration requires that oxygen be administered under the orders of a physician. R219 was admitted with diagnoses including cystitis without hematuria and had a moderate cognitive impairment with a BIMS score of 12 out of 14. A review of R219's physician orders did not reveal an order for oxygen use. However, progress notes from 01/20/25 documented that R219 was receiving oxygen via nasal cannula while lying in bed. An observation on 02/04/25 confirmed that R219 was receiving oxygen at 3 liters per minute via nasal cannula. During an interview, RN7 confirmed that there was no active order for oxygen and stated that oxygen should not be administered without an order, even in acute situations, unless an order is obtained. It was noted that the provider's note from the 4th indicated oxygen as needed, but the order was not transcribed.
Failure to Maintain Consistent RN Coverage
Penalty
Summary
The facility failed to ensure appropriate Registered Nurse (RN) coverage for 8 consecutive hours daily, 7 days a week, as required by regulation. A review of the facility's daily staffing sheets revealed that there was no RN coverage for specific dates, including 11/09/24, 12/21/24, 12/22/24, 12/25/24, 01/01/25, 01/04/25, and 01/05/25. Interviews with staff members, including a Certified Nursing Assistant (CNA), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the facility Administrator, confirmed the lack of RN coverage on these dates. The CNA mentioned frequent staff shortages due to turnover and sickness, while the LPN and DON described efforts to cover shifts, including using agency staff and having unit managers and the Assistant Director of Nursing (ADON) fill in as needed. The Administrator provided additional documentation of RN coverage but was unable to account for the missing dates. The DON stated that the facility always has RN coverage, even on weekends, and described the process for staffing and scheduling. Despite these assertions, the facility could not provide evidence of RN coverage for the specified dates, leading to the deficiency finding. The report highlights the facility's struggle with maintaining consistent RN staffing, which is crucial for meeting regulatory requirements and ensuring quality care for residents.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The facility's policy required gowns and gloves to be available immediately outside the resident's room, and PPE was necessary for high resident contact care activities. However, during observations, Certified Nursing Assistants (CNAs) were seen entering the resident's room without donning PPE, despite the resident having a PEG tube, which required such precautions. An empty PPE bin was noted outside the resident's room, indicating a lack of available PPE for staff to use. The resident involved had multiple medical conditions, including hemiplegia, dysphagia, and a history of traumatic brain injury, and was receiving nutrition and hydration via a PEG tube. Despite the facility's policy and the resident's care plan indicating the need for enhanced barrier precautions, staff interviews revealed lapses in compliance, with CNAs admitting to forgetting to wear PPE. The Director of Nursing acknowledged the expectation for management to observe staff using proper PPE and mentioned ongoing education efforts, but the deficiency persisted as staff failed to adhere to infection control protocols during care activities.
Failure to Maintain Sanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the Unit 4 shower room/toilet area. Observations revealed a stained toilet bowl with a dark, greenish dried substance and a foul odor, indicating a lack of cleanliness and maintenance. The shower room was also noted to have poor lighting. Despite the presence of feces in the toilet, the housekeeper responsible for cleaning the area reported not having access to the shower/toilet area due to not being provided with the necessary code. The housekeeping supervisor was unaware of the issue and confirmed the dim lighting, indicating a lack of communication and oversight in maintaining the facility's cleanliness and safety standards. Further observations showed that the maintenance assistant was seen transporting a soiled toilet, and the maintenance supervisor was unaware of the inoperable toilet and poor lighting conditions. The procedure for reporting broken equipment was not followed, as no maintenance request was submitted for the issues. The maintenance supervisor expressed surprise at the condition of the shower/toilet area and indicated plans to replace the lighting. The lack of a checklist for daily cleaning tasks further contributed to the oversight, as the housekeeping supervisor only had a checklist for monthly deep cleans, not for everyday cleaning duties.
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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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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