Piedmont Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Piedmont, South Carolina.
- Location
- 109 Bentz Road, Piedmont, South Carolina 29673
- CMS Provider Number
- 425314
- Inspections on file
- 22
- Latest survey
- April 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Piedmont Post-acute during CMS and state inspections, most recent first.
Failure to Check Hot Food Temps During Meal Service: A DA placed new batches of fried chicken and macaroni and cheese on the tray line and plated them without checking temperatures, despite a facility policy requiring hot and cold food temps to be taken before each meal service. The ADD questioned the DA, who admitted the chicken temp had not been taken, and the Administrator stated that any additional food prepared must also have its temp checked.
Staff failed to follow infection control practices during trach care and wound care by not performing hand hygiene between dirty and clean tasks and by not changing gloves appropriately. Staff also failed to follow contact precautions for a resident with MRSA and C. diff history when delivering meal trays without PPE or hand hygiene. In addition, the facility’s Legionella water management program was incomplete and lacked required monitoring, control, and response elements.
Medication administration errors exceeded the allowed rate, with 6 errors in 44 opportunities. An LPN gave a resident the wrong famotidine dose, another LPN administered incorrect ferrous sulfate and fish oil doses to a resident with severe cognitive impairment, and a third LPN gave saline nasal spray instead of ordered fluticasone to a resident with intact cognition. Staff stated the medications given did not match the prescriber orders, and the DON and Medical Director confirmed the discrepancies.
Failure to remove a lidocaine patch per physician order. An LPN found a lidocaine 5% patch still on a resident’s sacrum during med pass and removed it before applying a new patch, even though the order required removal by the scheduled time. The resident had intact cognition and was receiving scheduled pain medication. Staff, including the DON, Medical Director, and consulting pharmacist, stated the patch was expected to be removed as ordered, and the pharmacist noted manufacturer guidance limiting use to 12 hours in a 24-hour period.
A resident with constipation, bowel incontinence, and declining cognition had no documented bowel movements for extended periods, despite bowel meds, standing orders, and a care plan requiring every-shift monitoring. Staff gave inconsistent accounts of who was responsible for tracking bowel activity, several nurses said they relied on CNAs or alerts, and the resident was not listed on the bowel alert reports. Hospice later noted constipation and added a suppository, after which the resident reported a hard bowel movement and said it had been about two weeks since the last one.
Failure to Provide Proper Catheter Care: A resident with an indwelling urinary catheter and intact cognition received catheter care that did not follow facility policy. During observation, a CNA cleaned the catheter area but did not separate the labia or cleanse the urethral meatus, and later stated she thought she had done so but had not. The Administrator stated staff were expected to follow the facility’s catheter care policy.
Inaccurate Documentation of Lidocaine Patch Removal: A resident with intact cognition and a scheduled pain regimen had a lidocaine patch ordered to be applied daily and removed on schedule. The MAR showed the patch was removed by an LPN, but during observation another LPN found the patch still in place, removed it, and applied a new one. An LPN later stated the patch should have been removed on the prior shift, while another LPN could not recall whether she removed it.
A resident sustained a head laceration requiring staples after a CNA transferred them alone using a mechanical lift, contrary to facility policy requiring two staff members. The resident, with a history of dementia and mobility issues, was dependent on staff for transfers. Despite being aware of the policy, the CNA did not seek assistance from available staff, leading to the incident.
Failure to Check Hot Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure staff checked temperatures of all foods placed on the steam table for hot holding prior to meal service. A facility policy titled, Serving Temperatures for Hot and Cold Foods, effective 2020, stated that the cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. During observation on 04/03/2026 at 12:36 PM, Dietary Aide (DA)21 placed a new batch of fried chicken on the tray line and plated a resident's meal without taking the chicken's temperature. When the Assistant Dietary Director asked whether the temperature had been taken, DA21 stated that it had not. During continued observation of lunch service on 04/03/2026 at 12:55 PM and 12:56 PM, a new pan of macaroni and cheese was removed from the oven, placed on the tray line, and plated without a temperature check, and another new batch of fried chicken was taken from the fryer, placed on the tray line, and plated without a temperature check. During interview, DA21 stated she had multiple batches of fried chicken because she liked the food to be fresh. The Administrator later stated that the dietary department was expected to meet all temperature guidelines and that if additional food was prepared, its temperature must also be taken.
Infection Control and Water Management Failures
Penalty
Summary
Staff failed to follow infection control practices during tracheostomy care for a resident with acute and chronic respiratory failure and tracheostomy status. The resident had intact cognition and an order for tracheostomy care every shift. During observation, the respiratory therapist performed hand hygiene and donned clean gloves, but did not perform hand hygiene before putting on sterile gloves from the kit. After removing the dressing from around the resident’s neck and the tracheostomy collar, the therapist continued the procedure with the same gloves and did not change gloves or perform hand hygiene before cleaning the tracheostomy area. The therapist stated that hand hygiene was expected between glove changes and that after touching the dressing, a new pair of sterile gloves should have been donned. Staff also failed to follow infection control practices during wound care for a resident with stage IV pressure ulcers. The resident had intact cognition and an order for daily and as-needed wound care to the right lateral leg. During observation, the LPN performed hand hygiene and donned clean gloves, removed a dirty dressing, and then cleaned the wound while wearing the same gloves. The LPN also discarded one glove during the procedure and donned another clean glove without performing hand hygiene first. The LPN stated that hand hygiene was required between glove changes and before moving from a dirty procedure to a clean procedure. Staff failed to follow contact precautions for a resident with MRSA wound infection and a history of C. diff. The resident had an order for contact precautions and for care and therapy to be provided in the room. During observations, a CNA entered the resident’s room to deliver a meal tray without PPE, and on another occasion a CNA took the meal tray into the room without PPE and left without performing hand hygiene. Staff interviews showed mixed understanding of the PPE requirements, although the DON, ADON, DSD/Infection Preventionist, and Administrator stated that gown and gloves were expected when entering the room and delivering meal trays. The facility also failed to implement a complete Legionella water management program. The water management binder contained only a basic water description and did not include monitoring methods, control measures, control limits, a monitoring system, a response plan when limits were not met, or evidence of review. The Maintenance Director stated he did not monitor water unless something was brought to his attention and did not have written documentation showing monitoring points or risks for waterborne illness.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, with 6 errors out of 44 opportunities for a rate of 13.64% during medication administration observations for 3 residents. Facility policy stated medications are to be administered in accordance with prescriber orders, including any required time frame. For one resident with GERD and intact cognition, the order was for famotidine 20 mg daily, but an LPN administered one famotidine 10 mg tablet during the observed medication pass. The LPN stated the resident should have received two tablets for a total of 20 mg and acknowledged she was expected to follow the physician's orders. The DON and Administrator also stated the resident should have received two tablets instead of one. For another resident with muscle weakness and hyperlipidemia and severe cognitive impairment, the orders included ferrous sulfate 324 mg every Monday, Wednesday, and Friday and fish oil 1200 mg daily. During observation, an LPN administered ferrous sulfate 325 mg and fish oil 500 mg, two capsules by mouth. The LPN stated the facility did not have the ordered medications in stock and that the fish oil order had been changed after she spoke with the NP, but she acknowledged the medications were administered incorrectly. For a third resident with muscle weakness, infection, and COPD and intact cognition, the order was for fluticasone propionate nasal spray 50 mcg, but an LPN administered saline nasal spray 0.65% instead. The LPN stated she was told the saline spray was not the same as the ordered medication, and the Medical Director and DON stated the nurse should have checked with the NP and resident and documented that the ordered fluticasone was not available.
Failure to Remove Lidocaine Patch per Physician Order
Penalty
Summary
The facility failed to follow a physician’s order for a lidocaine external patch for one resident. The resident had diagnoses that included infection and inflammatory reaction due to an indwelling urethral catheter and muscle weakness, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition. The resident had an active order for a lidocaine 5% patch to be applied once daily for pain and removed per schedule, with the MAR transcribed to apply the patch at 9:00 AM and remove it at 8:59 PM. During medication administration observation, an LPN found a lidocaine patch dated the prior day still on the resident’s sacrum and removed it before applying a new patch. The LPN stated the patch should have been removed during the night shift per the physician’s order. Another LPN stated she could not remember whether she removed the patch, but said she was expected to remove it as ordered and that the patch was to be placed by day shift and removed by night shift. The Medical Director, Consulting Pharmacist, DON, and Administrator all stated staff were expected to follow physician orders for medication administration, and the pharmacist noted the manufacturer’s guidance that the patch should be removed after 12 hours and used only 12 hours within a 24-hour period.
Failure to Monitor and Document Bowel Movements
Penalty
Summary
The facility failed to ensure sufficient bowel monitoring for a resident with a history of constipation, major depressive disorder, and cognitive communication deficit. The resident was admitted in 2019 and later readmitted in 2025. The resident’s MDS showed the resident required substantial to maximum assistance with toileting and was always incontinent of bowel. A later significant change MDS showed severe cognitive impairment and hospice services. The care plan identified the resident as at risk for gastrointestinal problems related to constipation and GERD and directed staff to administer medications per orders, monitor and document bowel movements every shift, and monitor for signs and symptoms of gastrointestinal problems. The resident had active orders for GlycoLax in the morning for constipation, sennosides twice daily for constipation, and side effects monitoring for antidepressant medication every shift including constipation. Facility standing orders also included Colace or MOM for constipation. However, the resident’s MAR showed Colace and MOM were not administered during March 2026. The resident’s bowel documentation showed no bowel movements recorded from 03/12/2026 through 03/19/2026 and again from 03/21/2026 through 04/01/2026. The bowel continence task record also showed no bowel movements documented during those periods, with only isolated entries showing soft stool on 03/20/2026 and later hard stool and loose stool on 04/02/2026. Interviews showed inconsistent monitoring and communication among staff. Several nurses stated they relied on CNAs to report bowel movements or constipation concerns, while others stated they checked electronic reports or expected alerts to appear in the system. The unit supervisor stated she reviewed bowel movement reports and thought the resident may have been on the list on 03/27/2026 and 03/30/2026, but she did not document notifying a nurse. Other staff stated they were not notified that the resident had not had a bowel movement, and the resident was not listed on the alert reports during the periods reviewed. Hospice documentation later noted constipation and added a Dulcolax suppository, and the resident stated after the suppository that the bowel movement was hard as a rock and that it had been two weeks since the last bowel movement. The medical director stated it was disturbing that someone may have gone a two-week period without a bowel movement and no one knew about it.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure appropriate catheter care was provided for one resident with an indwelling urinary catheter. The resident had a history of neuromuscular dysfunction of the bladder and muscle weakness, and the annual MDS indicated intact cognition with a BIMS score of 15 out of 15. The resident’s care plan identified a risk for urinary system complications related to the indwelling catheter and directed staff to provide catheter care and empty the catheter every shift and as needed. An active order also required indwelling urinary catheter care every shift and as needed. During an observation of catheter care, a CNA gathered supplies, performed hand hygiene, donned PPE, and began care using warm water, liquid soap, and a clean washcloth. The CNA cleaned the Foley catheter from the outside of the labia to the area where the catheter was attached to the resident’s leg, but did not separate the labia or cleanse the urethral meatus. In interview, the CNA stated she thought she had cleansed the meatus but remembered that she had not. The Administrator stated staff were expected to follow the facility’s policy and procedures for catheter care.
Inaccurate Documentation of Lidocaine Patch Removal
Penalty
Summary
The facility failed to ensure that a resident’s medical record accurately reflected the removal of a physician-ordered lidocaine patch. The resident was admitted with a history that included muscle weakness and had intact cognition, with a BIMS score of 15 out of 15. The resident also received a scheduled pain medication regimen. The physician’s order directed that a lidocaine external patch 5% be applied daily for pain and removed per schedule, with the MAR transcribed to show application at 9:00 AM and removal at 8:59 PM. The MAR for March showed that an LPN initialed the record to indicate the patch was removed at 8:59 PM. However, during medication administration observation, another LPN found a lidocaine patch still on the resident’s sacrum, removed the dated patch, and applied a new one. In interview, that LPN stated the patch she removed should have been taken off during the night shift per the physician’s order. A second LPN stated she could not remember whether she removed the patch, but said she was expected to remove it as ordered and that day shift applied the patch while night shift removed it.
Failure to Follow Mechanical Lift Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that two staff members assisted with a mechanical lift transfer for a resident, resulting in the resident sustaining a laceration to the head. The facility's policy required at least two nursing assistants to safely move a resident with a mechanical lift, but this protocol was not followed. The incident occurred when a Certified Nursing Assistant (CNA) transferred the resident alone, and the sling bar of the lift swung and hit the resident on the head, causing a 3 cm laceration that required three staples to repair. The resident involved had a medical history that included dementia, anxiety disorder, bipolar disorder, schizophrenia, morbid obesity, muscle weakness, and abnormalities of gait and mobility. The resident was dependent on staff for chair-to-bed transfers and had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The care plan for the resident specified the use of a mechanical lift with two staff members for transfers, but this was not adhered to during the incident. Interviews with staff revealed that the CNA was aware of the requirement for two staff members but did not ask for assistance from the day shift staff, who were available at the time. The Director of Nursing (DON) and the Administrator confirmed that the CNA transferred the resident alone, which was against facility policy. The facility was not short-staffed, and the day shift staff were available to assist if requested. The incident was investigated, and it was determined that the failure to have two staff members present during the transfer led to the resident's injury.
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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