Physical Rehabilitation And Wellness Center Of Spa
Inspection history, citations, penalties and survey trends for this long-term care facility in Spartanburg, South Carolina.
- Location
- 8020 White Avenue, Spartanburg, South Carolina 29303
- CMS Provider Number
- 425175
- Inspections on file
- 29
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Physical Rehabilitation And Wellness Center Of Spa during CMS and state inspections, most recent first.
A resident with dysphagia, functional quadriplegia, memory problems, and an active NPO order, dependent on enteral nutrition, was able to receive and consume a cereal bar and water provided by visiting church members. A CNA and an LPN later found the resident with part of the cereal bar in the mouth and an empty cup, and the resident could not identify who had given the items. After ingestion, the resident developed vomiting, sweating, clamminess, and gurgling, with critically elevated BP, and was sent to the hospital, where records documented vomiting, intubation for airway protection, and suspected aspiration pneumonia. Surveyors determined this lack of supervision and control over outside food and drink constituted Immediate Jeopardy related to accident hazards and supervision requirements.
A facility failed to provide a written bed hold policy to a resident during a hospital transfer, as required by their policy. The resident, who had no cognitive impairment, was not given the notification prior to discharge. Interviews revealed confusion among staff about who was responsible for providing the policy, with the BOM and Admissions Director both unclear on their roles. The Administrator confirmed the policy should have been reviewed with the resident, but it was not completed.
A facility failed to update a comprehensive care plan for a resident with aggressive behaviors following an incident. The resident, with conditions including aphasia and moderate cognitive impairment, did not have new psychosocial interventions added to their care plan. Staff interviews revealed that the responsibility to update the care plan was overlooked due to miscommunication and the absence of a full-time MDS nurse.
The facility failed to implement proper infection control measures during wound care and medication administration, leading to potential cross-contamination. A resident with a stage 4 sacral wound did not receive care under Enhanced Barrier Precautions, and several LPNs did not follow hand hygiene and PPE protocols during medication administration. Additionally, the facility did not complete yearly reviews of its infection control policies.
A resident experienced increased anxiety during a dressing change when two male ambulance attendants entered the room, despite the situation not being an emergency. The LPN held the privacy curtain but proceeded with the report to the attendants, causing the resident discomfort. The DON later confirmed the transport was urgent, not emergent, and the attendants could have waited.
A facility failed to honor a resident's preference for showers, providing only two showers over two months instead of the scheduled two per week. The resident, who was cognitively intact, expressed dissatisfaction with receiving bed baths instead. The Social Service Director confirmed the discrepancy, highlighting a lapse in adhering to the facility's policy on resident dignity and self-determination.
The facility failed to issue necessary SNFABN and NOMNC forms to two residents, leading to a lack of information about Medicare coverage and potential liability. One resident was not given a SNFABN due to no appeal being filed, and another was informed of their last covered day by phone but did not receive a SNFABN. The SSD misunderstood the requirements, believing SNFABNs were only needed if an appeal was filed.
A facility failed to provide a written baseline care plan to a resident within 48 hours of admission, as required by policy. The resident, who was cognitively intact, did not receive the care plan despite it being documented and signed by staff. Interviews revealed that the Social Services Director sometimes forgot to deliver the plan if the resident was not easily found, and the DON indicated that the Social Worker should seek help if needed.
A facility failed to include a resident's religious preferences in their care plan, despite the resident being a Muslim and the care plan listing Christian-based activities. Staff were unaware of the resident's religious preferences, which were documented in the profile. Additionally, the facility did not develop a care plan for another resident's stage four pressure ulcer, despite having physician orders and a wound management summary. These deficiencies indicate a lack of person-centered care.
A facility failed to obtain a physician's order before administering oxygen to a resident with conditions including diabetes, asthma, and atrial fibrillation. The resident, who was cognitively intact, was observed receiving oxygen at two liters per minute without an order, contrary to the facility's policy. Both the ADON and DON confirmed the absence of the required order.
A facility failed to ensure proper communication with a dialysis center for a resident with end-stage renal disease, leading to incomplete documentation of dialysis sessions. The resident's records lacked information on shunt site, lab values, medications, and other critical observations. The DON stated that nurses should obtain verbal reports and assess residents upon return, but this was not consistently done.
A facility failed to maintain a medication error rate below five percent, resulting in an 11.54% error rate. Errors included an LPN initially setting an incorrect insulin dose, another LPN administering a chewable aspirin without instructing the resident to chew, and an LPN attempting to administer unsecured medication not prepared by herself. These incidents were discussed with the DON and Administrator.
The facility failed to properly label and store medications, as observed during a survey. An LPN administered insulin without open and discard dates, and another LPN found unsecured medication meant for a resident. The DON acknowledged these issues, emphasizing the need for proper medication management.
A resident undergoing dialysis found her breakfast tray left in her room for several hours, resulting in cold and unappetizing food. Despite staff reheating the meals, the resident expressed dissatisfaction. Facility staff were unaware of the potential food safety issues, with the Registered Dietician acknowledging the risk of foodborne illness. The Dietary Manager initially did not see a problem, while the Administrator and DON later agreed that a fresh, hot meal should be provided upon the resident's return.
The facility failed to ensure proper handling of ready-to-eat foods, as staff were observed preparing plates without gloves, potentially risking foodborne illness transmission to residents. The Dietary Manager and Administrator acknowledged the need for gloves when handling such foods, highlighting a compliance gap with FDA regulations.
The facility failed to document consent or refusal for flu and pneumonia vaccinations for two residents. One resident's record showed no documentation of vaccination or refusal, while another had outdated vaccination records with no further documentation. Interviews revealed a lack of awareness and responsibility among staff regarding vaccination documentation.
The facility failed to ensure a clean and safe environment, with observations of dirty baseboards, chipped doors, patched walls, sticky floors, and grime-covered kitchen mats. The Administrator was unsure of the last floor cleaning, and the Housekeeping Director followed a routine cleaning schedule, while the Maintenance Director mentioned hiring help for special projects.
Failure to Supervise NPO Resident Receiving Food and Fluids from Visitors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an NPO (nothing by mouth) resident was adequately supervised and protected from receiving food and fluids by mouth. The resident had an active physician’s order for NPO status and a care plan identifying high nutrition risk related to dysphagia and dependence on enteral nutrition for 100% of nutrient and energy needs, along with functional quadriplegia, history of subarachnoid hemorrhage, and epilepsy. The resident’s MDS indicated memory problems and use of a feeding tube as the nutritional approach. Despite these documented needs and restrictions, the resident was able to obtain and consume a cereal bar and water provided by visitors from a church group. On the day of the incident, a CNA observed the resident in his room with a cereal bar in his mouth and removed it from his hand, then notified the nurse. Another LPN later observed a cereal bar in a blue wrapper and a Styrofoam cup, noting that the resident had some of the bar in his mouth and some in his hand, with about half of the bar already in his mouth and all of the water gone. The resident could not identify who had given him the items. Staff interviews and the medical director’s account indicated that the food and drink were given by an unknown church member or group visiting the facility, and that such missionary visits were common on weekends. Following ingestion of the cereal bar and water, the resident developed symptoms including vomiting, sweating, clamminess, and gurgling, as documented in an Interact SBAR completed by an LPN. The SBAR noted that the event started with these symptoms after the resident ate a cereal bar from a church member, and recorded a blood pressure of 184/108. The NP reported being called by the nurse and informed that the NPO resident had received a cereal bar and water earlier that day and was now experiencing projectile vomiting and clamminess, and she ordered the resident to be sent to the hospital. Hospital records show the resident was admitted for vomiting, with a history of intracerebral hemorrhage, stroke, and schizophrenia, and was intubated for airway protection with suspected aspiration pneumonia, later requiring a tracheostomy. The state agency determined that the facility’s non-compliance with accident hazard and supervision requirements constituted Immediate Jeopardy at F689, effective as of an earlier date.
Removal Plan
- Assess the identified resident following the incident and implement provider orders.
- Discharge the resident to the hospital.
- Assess residents with nothing-by-mouth orders for change in condition, including changes in vital signs, respiratory distress, and gastrointestinal distress.
- Place a sign at the entrance of the facility instructing visitors and delivery drivers to consult with a nurse prior to delivering or providing food or drink to a resident.
- Post signs in rooms of residents with nothing-by-mouth orders identifying the resident as nothing by mouth and instructing staff/visitors to contact the nurse prior to providing any food or drink.
- Reeducate facility staff on the policy for food brought in from outside sources, including instructing staff to question visitors providing food/drink and to request visitors notify the nurse prior to providing food/drink to a resident.
- Complete audits of food distributed from outside sources to validate proper distribution.
- Hold an ad hoc QAPI meeting.
- Notify the Medical Director and provide updates on interventions completed.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident and/or their representative in a timely manner during a transfer to the hospital. According to the facility's policy, the bed hold policy should be provided at the time of admission and each time a resident leaves the facility for hospitalization or therapeutic leave. However, there was no documentation of a bed hold notification given to the resident or responsible party prior to the transfer. The resident, who had no cognitive impairment, was discharged to the hospital, but the facility did not follow its own procedures to ensure the bed hold policy was communicated. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for providing the bed hold policy. The Social Services Director indicated that the Business Office Manager (BOM) and Admissions were responsible for completing bed holds. However, the BOM, who was new to the role, believed that the admissions department was responsible for making contact. The Admissions Director, who had been at the facility for three months, stated she had never been instructed to handle bed holds and was unaware of the requirement to provide the policy at the time of transfer. The Administrator confirmed that the policy should have been reviewed with the resident upon leaving, regardless of the payor source, and acknowledged the task was not completed as there was no signed document available.
Failure to Update Care Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors. The resident, identified as R02, was admitted with diagnoses including aphasia, hemiplegia, and diabetes mellitus, and was moderately cognitively impaired. The care plan for R02, which was supposed to be updated following an incident on 11/29/24, did not include new psychosocial interventions or address the aggressive behavior. The existing care plan focused on monitoring the resident's mood and response to antidepressant medication but lacked specific interventions related to the incident. Interviews with facility staff revealed a breakdown in communication and responsibility. The Director of Social Services indicated that her assistant was supposed to update the care plan but failed to do so. Additionally, the Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's behaviors and necessary interventions. The absence of a full-time MDS nurse, who had recently quit, contributed to the oversight, as the part-time MDS nurse was not present to ensure the care plan was updated appropriately.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during wound care and medication administration, leading to potential cross-contamination. For Resident 25, who was cognitively intact and had a stage 4 sacral wound, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions (EBP) by failing to wear a gown and gloves during dressing changes. The nurse also did not wait for the appropriate dry time after using a Sani Cloth on the overbed table and used the same 4x4 gauze to pat the wound dry multiple times. Additionally, the nurse used the same gloves to open a Medi Honey container and apply it to the wound, which was stored with supplies for other residents. During medication administration, several Licensed Practical Nurses (LPNs) did not follow proper hand hygiene and personal protective equipment protocols. One LPN did not wear a gown while administering tube feeding to a resident with a PEG tube, despite the presence of an EBP sign. The LPN also failed to perform hand hygiene after removing gloves and touched various surfaces with contaminated gloves. Another LPN reused gloves and did not perform hand hygiene between tasks, while a third LPN did not clean the rubber septum of an insulin pen before use and failed to perform hand hygiene after glove removal. The facility also failed to complete yearly reviews of its infection control policies and procedures, with the last revision occurring in July 2023. The Director of Nursing and the Administrator acknowledged that the policies should have been reviewed annually but were not. These lapses in infection control practices and policy reviews had the potential to spread infections among the vulnerable population in the facility.
Failure to Promote Resident Dignity During Dressing Change
Penalty
Summary
The facility failed to promote dignity during a dressing change for a resident, identified as R25, which resulted in increased anxiety for the resident. R25, who was cognitively intact with a BIMS score of 15 out of 15, was undergoing a dressing change for a skin tear with MASD and was at risk for developing a pressure ulcer. During the dressing change, LPN5 entered the room and informed R25 that her roommate was being transported to the hospital. Despite the situation not being an emergency, LPN5 allowed two male ambulance attendants to enter the room while holding the privacy curtain together, which caused R25 to become anxious and attempt to cover herself. The Wound Care Nurse later apologized to R25 for the presence of the male attendants during the dressing change. In an interview, R25 expressed discomfort with the timing of the attendants' entry, stating that the dressing change could have been completed in about five minutes. LPN5 justified her actions by stating that she prioritized emergencies, while the Director of Nursing later confirmed that the transport was urgent but not emergent, indicating that the attendants could have waited for the dressing change to be completed.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident's preference for showers was respected, thereby denying the resident the right to self-determination. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was supposed to receive showers twice a week as per physician orders. However, the resident reported not receiving the showers as scheduled and instead was given bed baths. The resident expressed dissatisfaction with the lack of showers, indicating a preference for showers over bed baths. Upon review, it was found that the resident had only received two showers over a two-month period, despite the care plan and physician orders specifying two showers per week. The Social Service Director confirmed the discrepancy after checking the shower book for October and November. The facility's policy emphasizes the importance of maintaining resident dignity and self-determination, yet the failure to adhere to the resident's shower schedule indicates a lapse in following these guidelines.
Failure to Issue Required Medicare Notices
Penalty
Summary
The facility failed to issue accurate Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) and Notices of Medicare Non-Coverage (NOMNC) to residents, which are essential for informing them about their Medicare coverage and potential liability for services not covered. Specifically, Resident 74 was admitted for Medicare A services and was issued a NOMNC on 09/19/24, but was not given a SNFABN because the resident did not appeal. This oversight indicates a lack of proper procedure in issuing necessary notices regardless of whether an appeal is filed. Similarly, Resident 75, who was admitted for Medicare A skilled services, was informed by phone that their last covered day for skilled services was 07/19/24. However, the resident received services through a managed care plan, and the facility failed to issue a SNFABN, again due to the absence of an appeal. During an interview, the Social Services Director (SSD) revealed a misunderstanding of the requirements, believing SNFABNs were only necessary if a resident appealed a NOMNC. This misunderstanding led to the failure to provide residents with all necessary information to make informed decisions about their care.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. The resident in question, identified as R25, was admitted with diagnoses including diabetes mellitus, asthma, and atrial fibrillation. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the baseline care plan being documented and signed by staff members, there was no evidence that the written plan was given to the resident. Interviews conducted during the investigation revealed that the Social Services Director (SSD) sometimes forgot to provide the written care plan if the resident was not easily found in their room. The Director of Nursing (DON) acknowledged that the Social Worker was responsible for ensuring the resident received the written care plan and suggested that assistance should be sought if difficulties arose in completing this task. The resident, R25, confirmed not receiving any information from the staff regarding the care plan.
Failure to Address Religious Preferences and Pressure Ulcer in Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident, identified as R42, included the resident's religious preferences. R42, who was admitted with multiple diagnoses including chronic respiratory failure and chronic pain syndrome, was cognitively intact with a BIMS score of 15 out of 15. Despite this, the care plan did not accommodate R42's religious preferences, as the activities listed were Christian-based, and the resident, a Muslim, reported not being provided with appropriate religious accommodations. Interviews with facility staff, including the Activity Director, MDS Coordinator, Registered Dietician, Social Services Director, Dietary Manager, and the Administrator, revealed a lack of awareness regarding R42's religious preferences, which were documented in the resident's profile but not reflected in the care plan. Additionally, the facility failed to develop a comprehensive care plan for a stage four pressure ulcer for another resident, identified as R25. R25 was admitted with diagnoses including diabetes mellitus and atrial fibrillation and was coded as having a skin tear with MASD and at risk for developing a pressure ulcer. Despite having physician orders and a wound management summary indicating the presence of a stage four pressure wound, the care plan only addressed MASD and did not include a specific plan for the pressure ulcer. The Director of Nursing acknowledged the absence of a care plan for the pressure ulcer during an interview. These deficiencies highlight the facility's failure to provide person-centered care by not incorporating essential aspects of the residents' needs into their care plans. The lack of a comprehensive care plan for R42's religious preferences and R25's pressure ulcer had the potential to impact the residents' psychosocial and physical well-being, respectively.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order before administering oxygen to a resident, identified as R25, which was a requirement according to the facility's policy on oxygen therapy. R25 was admitted with diagnoses including diabetes mellitus, asthma, and atrial fibrillation, and was cognitively intact with a BIMS score of 15 out of 15. Observations on two separate occasions revealed that R25 was receiving oxygen at two liters per minute via nasal cannula. During an interview, the Assistant Director of Nursing confirmed that there was no order for the administration of oxygen for R25, acknowledging that an order was necessary. The Director of Nursing also confirmed that an order should have been in place for the administration of oxygen.
Lack of Communication with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper collaboration of care with the dialysis center for a resident requiring dialysis services. The resident, who was admitted with diagnoses of diabetes mellitus and end-stage renal disease, was receiving dialysis services while residing in the facility. The resident's physician orders indicated dialysis sessions on Mondays, Wednesdays, and Fridays. However, the Hemodialysis Communication Records provided by the facility showed missing documentation from the dialysis center on several dates. This included missing information about the shunt site, lab values, medications given, recommendations, food/fluid intake, and missing signatures and dates. Additionally, the communication sheets lacked documentation regarding the shunt observation, assessment of the auscultation of the bruit, palpation of thrill, and whether the resident reported pain. During an interview, the Director of Nursing stated that nurses are expected to call the dialysis center for a verbal report if the communication sheet is incomplete and to assess the resident upon their return to the facility. This lack of complete documentation and communication between the facility and the dialysis center had the potential to compromise the resident's care.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54% for three residents. The errors were identified during observations and interviews with staff. The first incident involved a Licensed Practical Nurse (LPN) administering insulin lispro to a resident. The nurse initially set the insulin pen to five units instead of the required four units, as per the resident's blood sugar level and physician's order. The error was corrected before administration, but it highlighted a lapse in attention to detail during medication preparation. In the second incident, another LPN administered a chewable aspirin to a resident without instructing them to chew it. The aspirin was given along with other tablets in a cup, and the nurse later acknowledged the mistake during an interview. This error demonstrated a failure to adhere to the correct administration route for the medication, as outlined in the facility's medication management policy. The third incident involved an LPN finding unlabeled and unsecured medication in a cart, which was meant for a resident who was away at therapy. The LPN attempted to administer the medication upon the resident's return, despite not having prepared it herself. This action was contrary to the facility's policy, which requires the same person to prepare, administer, and record medications. The Director of Nursing and the Administrator were informed of these errors, which were discussed during an interview.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was observed during a survey. In one instance, an LPN was seen taking an insulin lispro pen from a plastic bag labeled with a different medication, Lantus Solostar. The insulin pen was labeled with the resident's name and medication name but lacked the open and discard dates. The LPN admitted to not knowing when the pen was first opened and intended to administer it despite the missing information, citing the resident's blood sugar levels as justification. The Infection Preventionist later confirmed that the pen should have been marked with the necessary dates and discarded if undated. In another instance, an LPN found an unlabeled and unsecured medication cup containing two tablets in the medication cart, which were meant for a resident but had not been administered at the scheduled time. The Director of Nursing and the Administrator were informed of these issues, and the DON expressed that the insulin pen should have been discarded and that medications should not be administered if not withdrawn by the administering nurse. These lapses in medication management had the potential to lead to residents receiving incorrect or contaminated medications.
Failure to Ensure Food Palatability and Safety for Dialysis Resident
Penalty
Summary
The facility failed to ensure food palatability and safety for a resident undergoing dialysis, which had the potential to affect the resident's nutritional intake and cause food-borne illnesses. The resident, who was cognitively intact and had end-stage renal disease, attended dialysis three times a week, leaving the facility early in the morning and returning mid-morning. Upon return, the resident found her breakfast tray, which had been left in her room for several hours, with the food cold and unappetizing. Although staff sometimes reheated the food, the resident expressed dissatisfaction with the quality and temperature of the meals. Interviews with facility staff revealed a lack of awareness and understanding of the potential food safety issues associated with leaving the breakfast tray in the resident's room for extended periods. The Registered Dietician acknowledged the risk of foodborne illness and the unpalatability of reheated eggs, while the Dietary Manager did not initially recognize the problem, believing reheating was sufficient. The Social Service Director was unaware of the issue, and the Administrator and Director of Nursing later agreed that the practice was inappropriate, indicating a need for a fresh, hot meal upon the resident's return from dialysis.
Improper Handling of Ready-to-Eat Foods in Kitchen
Penalty
Summary
The facility failed to ensure proper handling of ready-to-eat foods in the kitchen, which could potentially lead to the transmission of foodborne illnesses to 107 of the 112 residents. During an observation, staff members were seen preparing plates without wearing gloves, despite handling ready-to-eat foods such as hamburgers and French fries. A staff member was observed adjusting food items on plates with bare hands before placing a dome on top, which is against the FDA regulations that require suitable utensils or gloves when handling ready-to-eat foods. Interviews with the Dietary Manager (DM) and the Administrator and Director of Nursing (DON) revealed a lack of adherence to proper food handling protocols. The DM acknowledged that gloves should be worn when touching ready-to-eat foods, yet staff were not required to wear gloves when checking plates and placing domes. The Administrator and DON confirmed that staff should not touch ready-to-eat food with bare hands, indicating a gap in compliance with food safety standards.
Failure to Document Vaccination Consent or Refusal
Penalty
Summary
The facility failed to offer or document consent or refusal for flu and pneumonia vaccinations for two residents, R25 and R37, out of a sample of 25. R25's electronic medical record showed no documentation of administration or refusal of the flu or pneumococcal vaccine. R37's record indicated the resident received one dose of PPSV23 in 2013, but there was no further documentation of additional pneumococcal vaccinations or refusals. This lack of documentation and action was identified during a review of the residents' immunization records. Interviews with facility staff revealed a lack of awareness and responsibility regarding vaccination documentation. The Infection Preventionist (IP) nurse acknowledged being unaware of the failure to meet vaccination requirements, while the Director of Nursing (DON) confirmed that the IP nurse was responsible for managing vaccinations. This oversight had the potential to increase the risk of flu and pneumonia for the affected residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and visitors. Observations revealed that the hallways had baseboards with a build-up of dirt and debris, and a door to a resident's room was chipped with missing pieces of wood. In one resident's room, a wall appeared to be patched with a piece of sheetrock and some white paint. Another resident's room had a sticky floor and a thick buildup of dirt and debris on the baseboard, some of which was easily wiped away. Additionally, the kitchen mats were observed to be dirty with grime build-up, with thick layers of grime between the holes of the mats. During an interview, the Administrator was unsure of the last time the floors were stripped and cleaned, and mentioned that painting was part of a special project the facility was preparing to implement. The Housekeeping Director indicated that a routine cleaning schedule was followed, with deep cleaning completed in one to two rooms a day, starting from the ceiling down. The Maintenance Director stated that someone had been hired to assist with special projects like painting, stripping, and waxing the floors.
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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