Pocotaligo River Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Manning, South Carolina.
- Location
- 3147 Sumter Hwy, Manning, South Carolina 29102
- CMS Provider Number
- 425114
- Inspections on file
- 16
- Latest survey
- January 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Pocotaligo River Health And Rehab during CMS and state inspections, most recent first.
A resident with multiple comorbidities, moderate cognitive impairment, high fall risk, and a care plan requiring use of a sit‑to‑stand lift for all transfers was instead moved to bed by a CNA using a manual stand‑pivot technique and lifting under the arms. During this transfer, a loud noise was heard, which the CNA attributed to shoe straps, and no immediate pain was reported. By the next morning, the resident reported severe leg and foot pain and stated their foot had been injured during the prior night’s transfer. Assessment showed swelling and tenderness of the left ankle and foot, and imaging confirmed oblique fractures of the distal tibia and fibula, after which the resident was hospitalized and underwent intramedullary rod insertion. The deficiency involves failure to follow the established transfer care plan and use of required lift equipment, resulting in fractures to the resident’s left lower extremity.
Staff failed to perform hand hygiene before handling clean dishes in multiple kitchens, and kitchenware was stored while still wet, contrary to facility policy. These deficiencies had the potential to affect nearly all residents receiving dietary services.
A resident and their representative were not given a written bed hold notice that included the required current per diem rate when the resident was transferred to a hospital. Although the bed hold policy and rate changes were reviewed at admission and mailed to representatives, the specific rate was not included on the notice at the time of transfer, leaving the resident without all necessary information.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with cognitive impairments was verbally abused by a CNA, who used profanity and yelled during care. The incident was witnessed by an LPN and reported to the DON. The resident reported frequent verbal abuse by the CNA, although no physical bruising was observed. Other residents did not report similar concerns.
The facility failed to ensure accurate labeling and dating of foods and maintaining safe temperatures for cold foods. Observations revealed opened food items without discard dates and cold food items served at unsafe temperatures. Staff interviews indicated a lack of consistent temperature checks once food leaves the kitchen, and the Registered Dietician admitted uncertainty about the functionality of hot plates used to maintain food temperatures.
The facility failed to properly clean a glucometer after use and did not ensure staff used appropriate PPE when handling soiled laundry. A nurse did not disinfect a glucometer after testing a resident's blood sugar, and laundry staff handled soiled linens with gloves but without aprons, contrary to facility policy. Interviews revealed a lack of adherence to infection control protocols.
A facility failed to develop a comprehensive care plan for a resident requiring dialysis, despite the resident's diagnoses of end-stage renal disease and dependency on dialysis. The care plan did not address dialysis treatment, and the issue was exacerbated by a system change that led to the loss of care plan files, causing delays in rewriting them manually.
A resident experienced significant weight loss due to the facility's failure to implement and monitor nutritional interventions. The resident's weight decreased from 156 to 142 pounds, and a prescribed nutritional supplement was discontinued prematurely. Documentation of meal intake was inconsistent, and the Registered Dietitian had not updated the resident's records. The Director of Nursing cited a transition to a new computer system as a reason for documentation errors.
The facility did not complete performance reviews for 4 out of 5 staff members, as required by their policy. The reviews lacked competency type and staff signatures. The DON acknowledged the oversight, attributing it to a busy day.
A facility failed to ensure a resident was free from unnecessary psychotropic medication. The resident was prescribed Seroquel for sleep without a documented diagnosis justifying its use, contrary to facility policy. Interviews revealed inconsistencies in the resident's diagnoses and the rationale for the medication, with the Medical Director admitting an oversight in not conducting a gradual dose reduction. The Administrator confirmed that every medication should have a diagnosis, but could not specify the timeframe for medication reviews upon admission.
Failure to Follow Transfer Care Plan Results in Resident Fractures
Penalty
Summary
The facility failed to ensure a safe transfer for a resident who required staff assistance and use of a sit‑to‑stand lift for functional transfers. The resident had multiple medical conditions including rheumatoid arthritis, osteoarthritis, muscle weakness, repeated falls, unsteadiness of feet, low back pain, radiculopathy, and dementia, and had a BIMS score of 9 indicating moderate cognitive impairment. The resident’s MDS documented dependence on staff for transfers and moving from sitting to standing, and the care plan directed staff to complete functional transfers using a sit‑to‑stand lift due to impaired balance. A fall risk evaluation identified the resident as high risk for falls, and the Kardex and care plan identified the resident as a “lift stand transfer.” Despite these documented needs and interventions, a CNA transferred the resident to bed using a stand‑pivot technique from the wheelchair to the bed instead of using the ordered sit‑to‑stand lift. The resident later reported that during this transfer the staff member lifted them under the arms and around the chest to place them in bed, and that a loud noise occurred at that time, which the resident described as sounding like a gunshot. The CNA reported hearing a noise during the transfer and believed it was the Velcro strap on the resident’s shoes, and the resident did not complain of pain at that time. No documentation in the report indicates that the CNA verified the resident’s transfer status or used the required mechanical lift during this transfer. The next morning, the resident complained of severe left leg and foot pain to an LPN, stating they thought their leg was broken and attributing the injury to the transfer the previous night when their foot hit the side of the bed. Subsequent nursing assessment identified swelling and tenderness of the left ankle and foot. An x‑ray of the left ankle revealed oblique fractures of the distal tibia and fibula with modest displacement and minimal callus formation. The resident was later admitted to the hospital with a diagnosis of closed fracture of the left tibia and fibula and underwent intramedullary rod insertion of the left tibia. The deficiency centers on the failure to follow the resident’s care plan and transfer requirements by not using the sit‑to‑stand lift during the transfer, which was associated with the resident sustaining fractures to the left ankle region.
Failure to Ensure Hand Hygiene and Proper Drying of Kitchenware
Penalty
Summary
Staff in four out of five facility kitchens failed to perform adequate hand hygiene while washing dishes, as observed during multiple instances. Dietary aides were seen moving from handling dirty dishes to removing clean dishes from the dishwasher without washing their hands. This was confirmed by both direct observation and staff interviews, where dietary aides acknowledged not performing hand hygiene before touching clean dishes. Facility policy required staff to wash hands before handling clean dishes, a requirement confirmed by both the Dietary Manager and Dietary Manager Assistant. Additionally, in the main kitchen, metal pans and plastic lids were observed to be stored while still wet, with water standing on them, indicating they were not thoroughly air-dried prior to storage. Both the Dietary Manager and Dietary Manager Assistant confirmed that all dishes were expected to be dry before being placed on storage shelves, and that there should be a designated area for items needing additional air-drying. These failures had the potential to affect 74 of 77 residents receiving dietary services.
Failure to Provide Complete Bed Hold Notice Including Current Per Diem Rate
Penalty
Summary
The facility failed to provide a resident or their representative with a written notice specifying the duration of the bed hold policy and the current rate for the reserve bed payment at the time of the resident's transfer to a hospital. Record review showed that the "Bed Hold Notice" given to the resident did not include the basic per diem rate, which is necessary information for decision-making regarding bed hold during a hospital stay. The facility's policy requires that written information about bed hold practices, including reserve bed payment, be provided to all residents and/or their representatives both in advance and at the time of transfer. Interviews with facility staff confirmed that the Social Services Director was responsible for completing the "Bed Hold Notice" forms and acknowledged that the basic per diem rate was omitted from the notice provided to the resident. Although the bed hold rates were reviewed with residents and representatives at admission and rate increases were mailed to representatives, this information was not included on the "Bed Hold Notice" at the time of the resident's transfer. The omission left the resident without all necessary information regarding the bed hold policy and associated costs.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident, identified as R1, from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved the CNA using profanity and yelling at R1 during care, which was witnessed by a Licensed Practical Nurse (LPN). The facility's policy on abuse clearly states that residents have the right to be free from all types of abuse, including verbal abuse, which is defined as the use of language that includes disparaging and derogatory terms. Despite this policy, the CNA was reported to have used abusive language towards R1, which was corroborated by multiple staff members. R1, who was admitted to the facility with diagnoses including dementia, anxiety disorder, and mild intellectual disabilities, was moderately cognitively impaired but able to understand and respond to verbal communication. During the incident, R1 was in a wheelchair and became upset, prompting the LPN to call for assistance. The CNA, who was known to be loud and rough, was reported to have yelled and cursed at R1, causing further distress. The LPN attempted to calm R1 and later reported the incident to the Director of Nursing (DON). Interviews with other staff members, including another LPN who overheard the incident over the phone, confirmed the CNA's inappropriate behavior. R1 also reported that the CNA frequently cursed at her, although no physical bruising was observed by the surveyor. Other residents on the same hall did not report any concerns of abuse, indicating that the issue may have been isolated to the interaction between the CNA and R1.
Deficiencies in Food Labeling and Temperature Control
Penalty
Summary
The facility failed to ensure accurate labeling and dating of foods, as well as maintaining safe temperatures for cold foods. During an observation in the kitchen, it was noted that several food items in the walk-in cooler, such as romaine lettuce and cucumbers, were opened and labeled with an open date but lacked a discard date. This is contrary to the facility's policy, which requires all ready-to-eat, potentially hazardous foods to be re-dated with a use-by date according to safe food storage guidelines. The Registered Dietician confirmed that staff are trained on proper procedures for receiving, labeling, rotating, and discarding items. Additionally, during a temperature check of cold items being served for lunch, several food items, including beets, chicken salad, and salads, were found to be at temperatures above the safe range. It was also discovered that food temperatures were not recorded prior to service for various wings of the facility. Interviews with the Dietary Aide and Homemaker revealed that when food temperatures are not in range, the procedure is to notify the manager or Registered Dietician for further instructions. However, it was noted that foods are not checked for temperature once they leave the kitchen and are brought to satellite kitchens, and the Registered Dietician admitted that they do not verify if the hot plates used to maintain temperatures are functioning properly.
Infection Control Deficiencies in Glucometer Use and Laundry Handling
Penalty
Summary
The facility failed to ensure the proper cleaning and disinfection of a glucometer during a medication pass observation. A registered nurse used an Assure Platinum glucometer to test a resident's blood sugar but did not clean or disinfect the device after use, contrary to the facility's policy and manufacturer recommendations. The nurse stated that the glucometer was not typically wiped since each resident had their own, indicating a misunderstanding or disregard for the infection control protocol. Additionally, the facility did not ensure that staff used appropriate personal protective equipment (PPE) when handling soiled laundry. Observations revealed that a laundry aide and the laundry supervisor handled soiled linens with gloves but without aprons or other necessary PPE. The laundry supervisor admitted that aprons were only worn during infection control outbreaks, which contradicts the facility's policy requiring PPE to prevent the spread of infection. Interviews with the Director of Nursing and the Infection Preventionist highlighted the expectation that staff should wear PPE at all times when handling soiled linens to prevent exposure to blood and body fluids. The facility's failure to adhere to these protocols was evident in the observed practices, which did not align with the stated policies and procedures for infection prevention and control.
Failure to Develop Comprehensive Care Plan for Dialysis
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R79, who required dialysis treatment. Despite the facility's policy mandating the creation of a person-centered care plan with measurable objectives and timeframes, the care plan for R79 did not address dialysis treatment and care. This oversight was discovered during a review of R79's comprehensive care plan, which lacked any mention of dialysis, despite the resident's diagnoses of end-stage renal disease, diabetes insipidus, diabetes mellitus, diabetic chronic kidney disease, acute kidney failure, and dependency on renal dialysis. The deficiency was further compounded by a change in the facility's computer systems on July 1, 2024, which led to the loss of care plan files. The Care Plan Coordinator admitted that the care plans were converted to PDF files but could not be located after the system change. As a result, the care plans were being manually rewritten, causing delays. The Administrator confirmed that all care plans were printed before the system change, with the intention of updating them as they became due, but the care plan for R79 was not updated to include dialysis treatment.
Failure to Maintain Nutritional Status of Resident
Penalty
Summary
The facility failed to ensure that interventions were in place to maintain the nutritional status of a resident, identified as R79, who experienced significant weight loss. Upon admission, R79 weighed 156 pounds, but over the course of several weeks, the resident's weight decreased to 142 pounds. Despite this weight loss, no interventions were implemented to prevent further decline. The facility's policy on weight monitoring emphasizes the importance of maintaining acceptable nutritional parameters and outlines a systemic approach to optimize nutritional status, which includes identifying risk factors, implementing interventions, and monitoring their effectiveness. However, these steps were not adequately followed for R79. The resident was prescribed a nutritional supplement, Nepro with Carb Steady, to be administered three times daily, but the supplement was discontinued prematurely on 07/18/24, and not reordered until 07/24/24, after further weight loss was noted. Additionally, there was a lack of documentation regarding the resident's meal intake on several days, and the Registered Dietitian had not made any notes in the medical record since 06/17/24. The Director of Nursing attributed some of these issues to a transition to a new computer system, which resulted in documentation errors, including the omission of the supplement administration.
Incomplete Performance Reviews for Staff Members
Penalty
Summary
The facility failed to provide completed performance reviews for 4 out of 5 staff members reviewed for employee performance. According to the facility's policy titled 'Competency Evaluation,' each employee is to be evaluated to ensure appropriate competencies and skills for their job and to meet the needs of facility residents. These competency forms are supposed to be maintained in the Staff Development Coordinator's office and then forwarded to the Human Resource Director for inclusion in the employee's personnel file. However, a review of 5 employee personnel files revealed that current performance reviews were missing for 4 of the staff members. Additionally, the Nurse Aide Competency Performance Reviews for these staff members lacked the competency type and the staff member's signature. During an interview, the Director of Nursing (DON) mentioned that the performance reviews would be brought shortly and explained that competencies are assessed based on patient acuity by unit managers, the Assistant Director of Nursing (ADON), and the DON. In a follow-up interview, the DON admitted to not knowing why the evaluations were unsigned, suggesting it was an oversight due to a busy day.
Failure to Ensure Resident Free from Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication. The resident, identified as R22, was admitted with diagnoses including orthopedic aftercare, Parkinsonism, and chronic obstructive pulmonary disease. However, there was no documented diagnosis justifying the use of Seroquel, an antipsychotic medication, which was prescribed for sleep. The facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition, and the medication's benefits must be documented. Despite this, R22's care plan did not include any diagnoses that required antipsychotic medication or a plan to monitor adverse effects. Interviews with the Medical Director (MD) and Registered Nurse (RN) revealed inconsistencies in the resident's diagnoses and the rationale for the medication. The MD admitted that the resident did not have a true diagnosis of dementia, which was initially used to justify the medication, and acknowledged an oversight in not conducting a gradual dose reduction. The RN also noted that the resident was taking Seroquel for behaviors, despite the absence of a documented diagnosis of dementia. The Administrator confirmed that every medication should have a diagnosis and that pharmacy conducts monthly drug reviews, but could not specify the exact timeframe for medication reviews upon admission.
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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