Pruitthealth- Ridgeway
Inspection history, citations, penalties and survey trends for this long-term care facility in Ridgeway, South Carolina.
- Location
- 213 Tanglewood Court, Ridgeway, South Carolina 29130
- CMS Provider Number
- 425288
- Inspections on file
- 26
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pruitthealth- Ridgeway during CMS and state inspections, most recent first.
Multiple cognitively impaired residents engaged in physical altercations, including scratching, hitting with closed hands, and slapping, on a secured and memory support unit. In several events, staff entered rooms or dining areas and observed one resident striking another, resulting in at least one skin tear and visible scratches, though no serious injuries were documented. One resident with a history of behavioral symptoms admitted to hitting another and expressed understanding after being told not to hit, yet the facility’s internal investigation initially recorded the event as unsubstantiated despite staff witness statements. Another resident with known socially inappropriate and aggressive behaviors slapped a wandering resident in the face after repeated room entries. The Administrator acknowledged that such incidents occurred frequently on the unit and that they usually substantiated these events as abuse, while also stating an expectation that all residents be free from abuse, including resident‑to‑resident abuse.
A resident with severe cognitive impairment, right AKA, hemiplegia, and dependence for mobility and ADLs had a prior unwitnessed fall from bed with head involvement and was subsequently identified as high risk for falls, with the care plan directing staff to keep the bed in the lowest position. Surveyors later observed on multiple occasions that the resident’s bed was elevated rather than kept low, including after a CNA entered and exited the room without adjusting the bed. In interviews, an RN acknowledged the bed was not in the lowest position despite the fall risk, the CNA stated she only learned that day the resident was a fall risk and should have lowered the bed, and an LPN confirmed the bed should be kept low and that staff do not document bed position each shift.
Two residents with documented memory problems and dependence or need for assistance with eating were seated at dining tables where their tablemates were fed and finished their meals before they themselves were served or assisted. On two separate lunch meal occasions, staff focused on feeding one resident at the table while another remained in a reclined geri-chair with no meal service or feeding assistance for an extended period, only receiving help after the tablemate had finished eating and left the dining room. An LPN later confirmed that some residents were served late due to a delayed meal cart and lack of communication, and both the Dietary Manager and DON acknowledged that residents at the same table should be served at the same time as a matter of dignity.
The facility failed to maintain sanitary conditions during meal service on the 200 Hall. CNAs were observed handling RTE food with bare hands and placing dirty trays on clean food carts, contrary to the 2017 FDA Food Code and facility policy. Staff interviews confirmed inconsistent adherence to these policies.
The facility failed to accurately post daily nurse staffing information, as required by policy, from late November 2024 to late January 2025. Instances included missing total hours worked, absence of RNs for required shifts, and blank entries for staff numbers and hours. The receptionist responsible for posting the information reported difficulties in obtaining the necessary data.
A resident with moderate cognitive impairment had expressed a desire to be DNR, with signed documentation and physician orders reflecting this status. However, the resident's Care Plan and Face Sheet incorrectly documented them as Full Code. Interviews with facility staff revealed confusion and inconsistency regarding the resident's code status, contributing to the failure to honor the resident's advance directives.
A resident was found in a room with a soiled mattress and suspected blood stain on the floor, indicating a failure to maintain a clean and homelike environment. Despite facility policies requiring routine cleaning, it was unclear if the scheduled deep cleaning was completed. Staff interviews revealed communication gaps and a lack of adherence to cleaning protocols.
A facility failed to conduct a PASRR for a resident prior to admission, as required by federal regulations. The resident, admitted with severe neurocognitive disorders, had their PASRR Level I screening completed months after admission. Interviews revealed that the facility lacks a specific PASRR policy and relies on federal regulations, with the hospital responsible for initial screenings.
The facility did not review and revise the care plans for two residents to include specific activities based on their preferences. One resident, with mobility issues, was unaware of any activities, while another, requiring encouragement, reported no participation in activities. The Activity Director and DON confirmed the absence of documentation for activity engagement.
The facility failed to provide an ongoing program of activities for two residents, as required by their policy. One resident with muscle weakness and amputations, and another with pulmonary edema and schizophrenia, reported not participating in any activities since admission. The Activity Director could not find documentation of their activity attendance, indicating a lack of adherence to the facility's policy.
A facility failed to implement physician orders for a resident's palm guards, intended to maintain or improve range of motion. The resident, in a persistent vegetative state with contractures, was observed without the prescribed palm guards, and staff were unaware of the orders. The DON confirmed that both CNAs and nurses are responsible for placing palm guards, but the facility lacked a specific policy for splints/devices.
A resident with a persistent vegetative state and other conditions had two contradicting orders for enteral tube feedings, leading to inconsistent feeding times. Staff interviews revealed a lack of awareness and communication regarding the resident's feeding orders, with discrepancies observed in the start times of the tube feedings. The facility's policy required verification of inappropriate orders, but this was not followed, resulting in a deficiency in care.
A facility failed to maintain a medication administration error rate below 5 percent, with a 10 percent error rate observed. An RN incorrectly primed insulin pens for two residents by keeping the cap on the needle and holding the pen horizontally, contrary to facility policy and instructions. This incorrect method was observed in three out of thirty opportunities, contributing to the high error rate.
Failure to Prevent and Substantiate Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse in the form of resident‑to‑resident altercations. Facility records and staff interviews show that one resident with dementia and mood disorder (R66) was involved in three separate physical conflicts on the secured unit. In one incident, a CNA entered a room and observed R66 scratching another severely cognitively impaired resident (R84) on the arm, resulting in a skin tear. In a second incident, an LPN at the nurses’ station saw R66 and another moderately cognitively impaired resident (R136) trying to pass through a doorway at the same time; R66 began flailing her arms and hit the other resident with open hands, after which the other resident struck R66 in the face with her fists. In a third incident, a CNA entered a room and saw R66 and another severely cognitively impaired resident (R120) grabbing each other; R66 had scratches on her face and blood on her mouth, and the other resident had scratches on her chest. Additional incidents involved other residents engaging in physical aggression toward one another. On one occasion, a resident with bipolar disorder (R93) approached a severely cognitively impaired resident (R125) who was seated in the dining room and struck her on the back multiple times with a closed hand. Staff witness statements documented that the striking was forceful and occurred multiple times, and progress notes recorded that the aggressor admitted to hitting the other resident and stated she understood after being told that hitting others was not acceptable. The facility’s internal investigation of this event was initially documented as unsubstantiated, despite staff accounts that the hitting occurred and that police were contacted for an incident number. The Administrator later acknowledged that this incident should have been substantiated as abuse because it happened. Another incident involved a severely cognitively impaired wandering resident (R115) and the same moderately cognitively impaired resident (R136) on the secured Memory Support Unit. Facility investigation notes indicated that R115 repeatedly wandered into R136’s room, prompting R136 to yell for her to get out. Staff redirected the wandering resident several times, and after the last entry into the room, staff seated R115 in the dining room. R136 then came from behind and slapped R115 in the face. The care plan for R136 already identified socially inappropriate and aggressive behaviors and directed staff to provide comfort measures when such behaviors began. The Administrator stated that residents on the Memory Support Unit “fight back there a lot” and that the facility usually substantiated such allegations because they occurred, noting that some residents did not like others in their personal space. Across these events, surveyors determined that the facility failed to ensure residents were free from physical abuse by other residents.
Failure to Maintain Low Bed Position for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and implement fall-prevention interventions as care planned for a resident with significant physical and cognitive impairments. The resident had diagnoses including right above-knee amputation, right hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, difficulty walking, and right-hand contracture. The resident sustained an unwitnessed fall from bed with head involvement, resulting in a hematoma to the right forehead and right eye, and was sent to the emergency room for evaluation. Subsequent assessments, including a Morse Fall Scale, identified the resident as high risk for falls, and the care plan was updated to direct staff to keep the bed in the lowest position due to the prior fall and the resident’s right AKA. Despite this care plan directive, multiple observations over two days showed the resident lying in bed with the bed elevated rather than in the lowest position. A CNA entered and exited the resident’s room without lowering the bed, and follow-up observations later that day and the next morning confirmed the bed remained elevated. During interviews, an RN acknowledged that the bed was not in the lowest position despite the resident’s fall risk and stated it should be as low as the mechanical bed would allow. The CNA reported that she only learned that day that the resident was a fall risk and that fall interventions were outlined in the care plan, including keeping the bed in the lowest position. Another LPN confirmed that the resident was at risk for falls and that the bed should be in the lowest position, and also stated that staff do not document bed position each shift.
Failure to Serve Tablemates Their Meals at the Same Time, Affecting Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents seated at the same dining table were served and assisted with their meals at the same time, affecting two residents reviewed for dignity in dining. One resident, identified as having short- and long-term memory problems and coded as dependent with eating on a significant change MDS, was observed seated in a reclined geri-chair at a dining table with her uneaten lunch tray in front of her while a CNA fed her tablemate. From 12:52 PM to 1:15 PM, the CNA continued feeding the tablemate while the dependent resident received no assistance with her meal. Only after the tablemate finished eating and was assisted out of the dining room did the CNA begin feeding the dependent resident at 1:17 PM, completing the feeding at 1:34 PM. The CNA confirmed that the dependent resident was served and assisted with her meal only after her tablemate had finished and left the dining room. A second resident, also documented on a quarterly MDS as having short- and long-term memory problems, was similarly affected on another day. This resident was seated in a reclined geri-chair next to the dining table without having been served a lunch meal, while staff fed the resident’s tablemate. From 12:35 PM to 12:45 PM, staff continued feeding the tablemate as the second resident remained without a meal and watched staff feed the tablemate. After staff finished feeding the tablemate and assisted her from the dining room at 12:47 PM, the second resident did not receive her lunch tray until 1:07 PM. The 400-hall unit manager (an LPN) confirmed that this resident was served later than her tablemate and explained that a second meal cart for the hallway arrived late due to a mix-up in the kitchen that was not communicated to hall staff. The Dietary Manager and the DON both acknowledged that residents seated at the same table should be served at the same time to promote dignity.
Sanitation Deficiency in Meal Service
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions during the meal service on the 200 Hall. Observations revealed that a Certified Nursing Assistant (CNA2) handled ready-to-eat (RTE) food with bare hands, which is against the 2017 FDA Food Code and the facility's policy. CNA2 was observed setting up meal trays for residents, touching food items such as rolls and sandwiches with bare hands, and not using suitable utensils as required. This action could lead to contamination of food and potential foodborne illness outbreaks. Additionally, another CNA (CNA1) was observed placing a dirty tray on a clean food cart and then serving a clean tray to a resident without sanitizing her hands. The food cart was left open during the service, which is against the facility's policy. Interviews with CNA1 and a Registered Nurse (RN2) confirmed that the policy of not placing dirty trays on the food cart is not consistently followed, and staff sometimes struggle to adhere to this policy. CNA2 also admitted to not being aware of the prohibition against touching food with bare hands.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of daily posted nurse staffing information, which is required to be visible and accessible to residents and visitors. The facility's policy mandates that daily nursing hours, including the total number of staff and their working hours, be posted prominently. However, from November 26, 2024, to January 26, 2025, there were multiple instances where the staffing information was incomplete or missing. Specific deficiencies included missing total hours worked, absence of Registered Nurses (RNs) for required shifts, and blank entries for actual staff numbers and hours worked. The report highlights several specific dates where the staffing information was not accurately posted. For example, on December 5, 2024, and January 8, 2025, the actual number of staff and total hours worked were not documented. Additionally, on January 18, 2025, and subsequent days, there were no records of staff numbers or hours worked. The receptionist, responsible for posting this information, reported difficulties in obtaining the necessary data despite multiple requests, indicating a breakdown in communication and process adherence within the facility.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's stated wishes and the documentation in their medical records. The resident, who had moderate cognitive impairment, had expressed a desire to be Do Not Resuscitate (DNR) and had signed documentation and physician orders reflecting this status. However, the resident's Care Plan and Face Sheet incorrectly documented the resident as Full Code, indicating a failure to update and maintain accurate records of the resident's advance directives. Interviews with facility staff, including a CNA, LPN, Admission staff, Social Worker, and the Director of Nursing, revealed confusion and inconsistency regarding the resident's code status. The CNA was unaware of the DNR status, while the LPN, Admission staff, and Social Worker all stated the resident was Full Code. The resident's representative was also uncertain and needed to verify the status. This lack of clarity and communication among staff members contributed to the failure to honor the resident's advance directives as per their wishes.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident, identified as R36, who was observed in a room with an unkempt and visibly soiled mattress. The mattress had crumbs and a brown, crusty substance on it, and there was a noticeable stain, suspected to be blood, on the floor near the bed. The facility's policy requires routine and consistent housekeeping services, including monthly deep cleaning of resident rooms and additional cleaning as needed. However, it was unclear if the scheduled deep cleaning for R36's room was completed as planned. Interviews with facility staff revealed a lack of communication and adherence to cleaning protocols. The Housekeeping Supervisor stated that CNAs are responsible for notifying housekeeping of any concerns, and that mattresses are scheduled for monthly cleaning. The Director of Nursing confirmed the existence of a deep cleaning schedule and communication methods for reporting cleaning issues, but was unaware of the condition of R36's room and mattress. This indicates a breakdown in the facility's procedures for maintaining a clean and comfortable environment for residents.
Failure to Conduct PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident received a Preadmission Screening and Resident Review (PASRR) prior to admission. The resident, identified as R101, was admitted with diagnoses including metabolic encephalopathy, vascular dementia with severe agitation, and other neurocognitive disorders. Despite these conditions, the PASRR Level I screening form was only completed on July 29, 2024, well after the resident's admission date of February 16, 1959. This indicates a lapse in the required preadmission screening process as per federal regulations. Interviews with facility staff revealed that the social worker typically runs an ICD 10 report monthly to determine if a Level II screening is warranted, and it was noted that the hospital is responsible for completing the Level I PASRR prior to admission. However, the Director of Nursing (DON) admitted that the facility does not have a specific PASRR policy and relies on federal regulations. The DON also mentioned that the resident is on hospice care and has experienced an overall decline, which may have contributed to the oversight in the PASRR process.
Failure to Implement Comprehensive Activity Plans for Residents
Penalty
Summary
The facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for two residents, R29 and R100, to include goals and interventions for an ongoing program of activities based on their preferences. R29, admitted with diagnoses including muscle weakness and bilateral lower limb amputations, had a care plan that identified a preference for activities related to his prior lifestyle but did not include any specific interventions or preferences. During an interview, R29 expressed unawareness of any activities and stated he had not been invited to participate in any. Similarly, R100, admitted with conditions such as acute pulmonary edema and schizophrenia, had a care plan indicating a preference for one-on-one activities and required encouragement to participate. However, the plan only included a general intervention for staff to verbally encourage participation. R100 reported not having participated in any activities or received one-on-one attention. The Activity Director and the Director of Nursing confirmed the lack of documentation to show that either resident had engaged in activities since their admission.
Failure to Provide Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being of residents, as required by their policy. Specifically, two residents, R29 and R100, were not engaged in any activities since their admission. R29, admitted with diagnoses including muscle weakness and bilateral lower limb amputations, reported not being invited to any activities or receiving one-on-one activities. Similarly, R100, with conditions such as acute pulmonary edema and schizophrenia, stated she had not participated in any activities or received individual attention. The Activity Director, a new employee, was unable to find documentation of activity attendance for these residents, indicating a lack of adherence to the facility's policy. The policy mandates that the center should offer a variety of recreational programs tailored to residents' interests and capabilities, with participation recorded in the Electronic Health Record. However, no such records were found for R29 and R100, highlighting a deficiency in the facility's activity program implementation.
Failure to Implement Physician Orders for Palm Guards
Penalty
Summary
The facility failed to carry out physician orders for a resident's splint/palm guard, which was intended to maintain or improve the resident's range of motion (ROM). The resident, who was in a persistent vegetative state and had contractures in the right elbow, right hand, and left hand, was dependent on others for all aspects of care. The resident's care plan included the application of palm guards to both hands daily during the day shift for 8 hours, as well as passive range of motion exercises. However, during observations, the resident was found without the prescribed palm guards, and nursing staff were unaware of the orders, indicating a lapse in following the care plan. Interviews with nursing staff revealed a lack of awareness regarding the resident's orders for palm guards, with one nurse stating that they typically used rolled towels for positioning instead. Another nurse confirmed the existence of the orders and placed the palm guards on the resident after being informed. The Director of Nursing stated that both CNAs and nurses are responsible for placing palm guards and have access to the care plans and orders, yet the facility did not have a specific policy for splints/devices. This oversight had the potential to cause further decrease in the resident's ROM and/or pain.
Inconsistent Tube Feeding Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving enteral tube feedings was provided with appropriate treatment and services to prevent complications. The resident, who was in a persistent vegetative state and had conditions such as dysphagia, gastroparesis, and gastro-esophageal reflux disease, had two contradicting orders for enteral tube feedings. The facility's policy required that any inappropriate orders be verified with the attending physician, but this was not adhered to in the case of the resident. Observations revealed discrepancies in the start times of the tube feedings, with the feed being labeled and dated with different start times on consecutive days. Interviews with staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Dietitian, highlighted a lack of awareness and communication regarding the resident's feeding orders. The RN was unaware of the variations in orders and stated that efforts are made to reconcile orders weekly. The DON emphasized the expectation for nursing staff to clarify discrepancies with providers, but was unaware of the multiple orders. The Dietitian confirmed the current feeding order and noted an increase in the feed rate, but was uncertain about the change in the feeding schedule. This lack of coordination and communication among staff led to the deficiency in providing appropriate care for the resident with a feeding tube.
Insulin Administration Errors Due to Incorrect Priming
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5 percent, as evidenced by a 10 percent error rate in insulin administration. Specifically, the insulin flex pens for two residents were not primed correctly prior to administration. The facility's policy on insulin injections, revised on 07/18/2024, requires that insulin pens be primed by dialing 2 units and pressing the button until insulin secretes from the needle. However, during observations, a registered nurse (RN) was seen priming the insulin pens with the cap on the needle and holding the pen horizontally, which is contrary to the facility's policy and the instructions from The Institute of Family Health. During the observations, the RN prepared insulin injections for two residents using Novolin 70/30 Kwik Pen, Lantus, and Humalog pens. In each instance, the RN primed the pens incorrectly by keeping the cap on the needle and holding the pen horizontally, rather than pointing the needle upwards as required. When questioned by the surveyor, the RN admitted to feeling nervous and confirmed that she had primed the pens incorrectly. This incorrect priming method was observed in three out of thirty opportunities, contributing to the facility's medication administration error rate exceeding the acceptable threshold.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
