Ridgeland Nursing Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ridgeland, South Carolina.
- Location
- 1516 Grays Highway, Ridgeland, South Carolina 29936
- CMS Provider Number
- 425132
- Inspections on file
- 21
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ridgeland Nursing Center Inc during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen's walk-in refrigerator, such as leftover meat, sausage links, orange juice, and cheese, were not labeled or dated, and prepared tea cups lacked proper lids. Additionally, meat patties were served at an unsafe temperature of 126°F before being reheated, with the Dietary Manager acknowledging the failure to meet required cooking standards.
A resident with severe cognitive impairment was unable to receive visitors after posted visiting hours due to facility restrictions and unanswered after-hours calls. A family member was denied re-entry after leaving briefly, and repeated attempts to contact staff via the posted phone number were unsuccessful. Staff interviews confirmed that the phone was not consistently answered after hours, and portable phones for resident use were often unavailable. These actions prevented the resident from receiving visitors and phone calls as desired.
Two residents were affected when bedside fall mats were found soiled with a dried brown substance and window blinds were observed to be bent and nonfunctional. Staff interviews revealed confusion over cleaning responsibilities, and the Administrator was unaware of the broken blinds, indicating a lack of consistent monitoring by maintenance.
Two residents were involved in a physical altercation, with one admitting to hitting the other after an accusation of theft. The incident was documented by an LPN and later confirmed by both residents in interviews. However, the DON did not report the event to the state survey agency as required by facility policy, nor were timely interviews conducted. This failure to report the abuse allegation had the potential to impact all residents.
The facility did not investigate an incident where two residents were involved in a physical altercation, despite both confirming the event and staff intervening. The facility's policy requires investigation of all alleged abuse, but the DON stated no investigation was conducted because abuse was not suspected.
Two residents who were transferred to the hospital did not receive the required written transfer notices, as confirmed by review of their electronic medical records and an interview with the Administrator, who stated the facility was not aware of the requirement to send such notices.
A resident with intellectual disabilities was administered continuous oxygen therapy at two liters per minute without an active physician order. Staff observations and interviews revealed that an LPN believed an order was in place, but had not recently verified it, while the NP confirmed the order had been discontinued and was unaware oxygen was still being given. The DON stated staff should check orders with each assessment, but the resident continued to receive oxygen therapy without a valid order.
A resident with intellectual disabilities was provided with bilateral side rails at family request without documented exploration of alternatives or assessment for entrapment risk. Staff interviews confirmed that alternatives were not considered and entrapment risk was not assessed prior to side rail use.
Two residents were not offered or administered the pneumococcal vaccine as required by facility policy, and there was no documentation of the vaccine being offered or refused. One resident with severe cognitive impairment and another who was cognitively intact both lacked evidence in their records of being offered or receiving the vaccine, despite their medical conditions indicating the need for immunization. The DON confirmed the absence of documentation and that the required process was not followed.
A facility failed to develop a comprehensive care plan for a resident with complex medical conditions, including anticoagulant therapy, leading to an incident where the resident sustained a bleeding injury. The MDS Coordinator was behind on care plans, and the facility lacked a process for revising them after interdisciplinary team meetings.
Improper Food Storage and Inadequate Cooking Temperatures Identified in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage and handling in the facility's kitchen. During an inspection of the walk-in refrigerator, several food items, including leftover meat, sausage links, a pitcher of orange juice, and an opened package of cheese, were found without labels or dates. Additionally, prepared cups of tea did not have properly fitting lids, and the Dietary Manager (DM) was unable to account for the correct lids. The DM was unable to identify some of the unlabelled food items and acknowledged that the juice in the pitcher was not used for service, as the facility used a juice dispenser instead. Further observations revealed that food was not always cooked to the proper temperature before being served. The DM checked the temperature of meat patties being served and found them at 126°F, which is below the required safe temperature. Despite recognizing that the temperature was inadequate, the DM continued to serve some of the meat patties before reheating a portion to the correct temperature. Upon reheating, the patties reached 155°F but became dry and tough. The DM stated that the expected standard was to cook meat patties to 165°F with a holding temperature of 135°F.
Failure to Honor Resident Visitation Rights Due to Restricted Visiting Hours and Unanswered After-Hours Calls
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at any time, as required. A sign posted at the facility entrance restricted visiting hours to 7:00 AM to 7:00 PM, with re-entry after 7:00 PM only allowed with authorization via a listed phone number. Staff interviews confirmed this policy, and the receptionist stated she typically left before 5:00 PM, leaving after-hours calls to be answered by nursing staff. However, neither the Director of Nursing nor the Administrator had ever audited whether the phone was answered after hours, and both acknowledged that nursing staff were responsible for answering the phone but might be too busy to do so. A family member of a resident with severe cognitive impairment reported being denied re-entry after 7:00 PM despite attempting to call the posted number multiple times without success. Observations confirmed that the phone was not answered after hours and had no voicemail service. The family member also reported difficulty reaching the resident by phone during business hours, as calls were often not answered and portable phones were unavailable due to uncharged batteries. These actions and inactions resulted in the resident being unable to receive visitors or phone calls as desired, violating their rights and potentially affecting all residents in the facility.
Failure to Maintain Clean Equipment and Functional Room Furnishings
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not ensuring that resident equipment and room furnishings were properly cleaned and maintained. Specifically, one resident's bedside fall mats were observed on multiple occasions to have a dried brown substance splattered on them. Interviews with housekeeping and CNA staff revealed confusion regarding responsibility for cleaning bedside equipment, with both groups indicating the other could be responsible. The Assistant Director of Nursing confirmed the mats were soiled and stated the expectation was for staff to clean spills immediately. The Director of Nursing indicated that housekeeping was responsible for cleaning the mats, but also expected staff to check and clean soiled equipment throughout their shifts. Additionally, another resident's window blinds were found to be bent and not in good working order during several observations. When the window was opened, the blinds flapped in the wind and could not be raised due to the bent slats, with the center of the blinds falling from the support. The Administrator was unaware of the issue and stated that maintenance was responsible for ensuring window blinds were in good working order, but acknowledged that she had not visually inspected the blinds or ensured consistent monitoring by maintenance staff. These deficiencies were identified through direct observation and staff interviews.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents, as required by its Abuse Prevention Policy and Procedure. The policy mandates that any incident involving alleged mistreatment, neglect, exploitation, or abuse, including injuries of unknown source, must be immediately reported to the appropriate authorities, including the state survey agency. On the date in question, a nurse's note documented that one resident was "throwing punches" with another resident. Both residents later confirmed in interviews that a physical altercation occurred, with one resident stating he hit the other in the face after being accused of taking money. Staff intervened and separated the residents at the time of the incident. Despite the clear documentation and resident admissions of a physical altercation, the incident was not reported to the state survey agency as required. The Director of Nursing stated that abuse was not suspected and therefore the incident was not reported within the mandated two-hour timeframe. Additionally, the DON confirmed that interviews with the residents were not conducted within two hours of the incident, and the event was not entered into the facility's reportable logs. This failure to report had the potential to affect all residents receiving care in the facility.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. According to the facility's Abuse Prevention Policy and Procedure, any alleged mistreatment, neglect, or abuse must be documented and investigated, including gathering information about the incident, interviewing all pertinent parties, and maintaining records. However, a review of the records showed that after an altercation where one resident struck another in the face following an accusation of theft, there was no documented investigation into the incident as required by policy. Both residents involved had recent admissions and relevant diagnoses, with one being cognitively intact and the other moderately cognitively impaired. Interviews with both residents confirmed the physical altercation, and staff intervention was noted. Despite these facts, the DON stated that no investigation was conducted because abuse was not suspected, which was inconsistent with the facility's policy and procedures for handling such allegations.
Failure to Provide Required Written Transfer Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written transfer notice containing all required information to two out of five residents, or their representatives, who were reviewed for hospital transfers. For one resident with intellectual disabilities and a BIMS score indicating cognitive intactness, there was no evidence in the electronic medical record (EMR) that a written notice of transfer was given after a facility-initiated hospital transfer. Similarly, for another resident with major depressive disorder and moderate cognitive impairment, the EMR did not show that a written notice of transfer was provided after two separate facility-initiated hospital transfers. Record reviews of the residents' admission records, quarterly Minimum Data Set (MDS) assessments, and various EMR tabs (Evaluations, Documents, Progress Notes) failed to reveal documentation of the required transfer notices. During an interview, the Administrator confirmed that the facility had not been sending out transfer notices when residents were discharged and stated unawareness of this requirement.
Oxygen Therapy Administered Without Active Physician Order
Penalty
Summary
The facility failed to ensure that a resident received safe and appropriate respiratory care by administering continuous oxygen therapy without an active physician's order. Record review showed that the resident was admitted with intellectual disabilities and had a care plan indicating continuous oxygen therapy. However, there was no current physician order for oxygen administration in the electronic medical record. Observations over several days confirmed that the resident was receiving oxygen at two liters per minute via nasal cannula. Interviews with staff revealed that an LPN believed there was an active order for continuous oxygen, but had not checked the order recently. The nurse practitioner confirmed that the order for oxygen had been discontinued and was unaware that the resident was still receiving oxygen. The DON stated that staff are expected to verify physician orders each time they assess a resident and to discontinue treatments when orders are discontinued. Despite these expectations, the resident continued to receive oxygen therapy without a valid order.
Failure to Assess Alternatives and Entrapment Risk Before Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted prior to the installation of side rails and did not complete a proper assessment for the risk of entrapment for a resident with intellectual disabilities. Record review showed that the resident was admitted with intellectual disabilities and had a care plan intervention for bilateral side rails at the request of the family. However, there was no physician order for side rail use, and documentation did not show that alternatives to side rails were explored or that an entrapment risk assessment was completed. Observations confirmed that the resident was in bed with full side rails up on both sides. Interviews with the MDS Coordinator and the DON revealed that the facility was not exploring alternatives before using side rails and was not assessing for entrapment risk. The staff stated they were unaware of these requirements, and the only actions taken were a side rail assessment and obtaining signed consent, without considering or documenting alternative interventions or entrapment risk.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received pneumococcal vaccinations as required by their own policy and current recommended practice guidelines. For one resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, diabetes, and chronic kidney disease, records showed that the pneumococcal vaccine was not up to date and had not been offered. The resident's immunization record confirmed that neither the vaccine was administered nor the offer documented. For another resident, who was cognitively intact and had diagnoses including cerebral infarction and hemiplegia, the Minimum Data Set indicated the vaccine was up to date, but there was no supporting documentation in the immunization record to confirm administration or offer of the vaccine. During interviews, the DON confirmed that both residents had not received or been offered the pneumococcal vaccination prior to recent attempts to obtain consent or offer the vaccine. The DON also acknowledged the lack of evidence to support claims that the residents or their representatives had previously been offered the vaccination or had refused it. The facility's policy required that residents be offered the pneumococcal vaccination and that refusals be documented, but this was not done for the two residents reviewed.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, who was admitted with multiple complex medical conditions, including acute duodenal ulcer with perforation, hypertension, and acute kidney disease with renal dialysis. The resident was assessed with a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment and required extended or total assistance for all activities of daily living (ADLs). Despite these needs, the care plan did not address the potential risk for accidents, skin condition, or increased bleeding related to the resident's anticoagulant therapy. The deficiency was further compounded by the facility's lack of a process for revising care plans after the interdisciplinary team identified a need for development or revision. The MDS Coordinator, who was solely responsible for care plan development and revisions, admitted to being behind on comprehensive care plans since January 2024. The facility had initiated a performance improvement plan and engaged a consulting agency to assist with training and education, but the care plans remained outdated, contributing to the incident where the resident sustained a bleeding injury requiring hospital treatment.
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.
