Riverside Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, South Carolina.
- Location
- 2375 Baker Hosp Blvd, Charleston, South Carolina 29405
- CMS Provider Number
- 425082
- Inspections on file
- 22
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Riverside Health And Rehab during CMS and state inspections, most recent first.
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.
Surveyors found that food items in the refrigerator were not labeled or dated, dry storage bins for sugar and flour contained Styrofoam cups in direct contact with food instead of proper scoops, and dirty trays and food debris were present in the kitchen prep area. The oven was observed to have thick grease and food debris, and staff interviews confirmed lapses in labeling, dating, and cleaning procedures.
Three residents with upper extremity contractures did not receive hand splinting as recommended by OT, due to missing orders, lack of care plan updates, and poor communication between therapy and nursing. Observations showed splints not in use and staff unaware of splinting needs, despite documented recommendations and physician orders.
The facility did not ensure resident dignity by serving meals in Styrofoam containers to most residents due to unwashed kitchenware, and failed to protect a resident's physical privacy during medication administration when an LPN left the door open and did not use the privacy curtain, making the resident visible from the hallway.
Two cognitively intact residents were observed with medications left unattended at their bedside without proper assessment or authorization for self-administration, contrary to facility policy. An LPN and RN confirmed that no residents had been assessed for self-administration, and staff interviews revealed that some residents also kept or ordered their own over-the-counter medications, which were not consistently monitored or removed.
Surveyors observed an uncovered and overflowing garbage container near the food preparation area, with paper towels and gloves on the floor. The Dietary Manager confirmed this was unacceptable and that garbage should be contained or emptied before overflowing.
An LPN was observed carrying unbagged soiled linen out of a resident's room and placing it in a laundry cart, contrary to facility policy requiring soiled linen to be bagged before removal. The resident was on Enhanced Barrier Precautions due to an enteral feeding tube and had a history of UTI and dysphagia. Staff interviews confirmed the expectation that soiled linen should be bagged to prevent infection spread.
The facility did not update its daily nurse staffing posting, displaying outdated information in a common area accessible to residents and visitors. Both the Assistant Administrator and DON confirmed the posting was not current and should have reflected the actual staffing for the day.
A resident with moderate cognitive impairment was mistakenly taken by a transport company, and the facility failed to identify the resident as missing or implement emergency protocols in a timely manner. Staff assumed the resident was visiting friends, and it was not until the resident missed medications and dinner that his absence was noted. The resident was later found at a local Waffle House and returned to the facility.
A resident with moderate cognitive impairment eloped from the facility due to inadequate supervision and communication failures. The resident was mistakenly taken by a transport company instead of the intended resident, and staff did not realize the resident was missing until later. The facility failed to report the incident promptly, and the resident was eventually found by police at a local Waffle House.
The facility did not conduct smoking assessments for 4 out of 10 residents who smoke and failed to enforce safety protocols for all 10 residents. Observations revealed residents smoking across a busy street without supervision or safety equipment. Residents expressed concerns about safety and admitted to keeping smoking materials on their person, contrary to facility policy. Medical records indicated specific risks for residents with conditions like COPD and chronic bronchitis, increasing the hazard of unsupervised smoking. Staff interviews highlighted a lack of awareness and oversight regarding smoking assessments and protocols, contributing to the identified deficiency.
The facility failed to provide clean linen and washcloths to residents, as evidenced by multiple observations of stained, dirty, or missing linens in several rooms. Residents expressed ongoing frustration over the issue, which had been discussed in Resident Council Meetings for several months without resolution. The DON acknowledged the problem, attributing it to an outsourced laundry service, and stated that laundry services would be conducted in-house starting next month.
The facility failed to provide sufficient RN staffing on a 24-hour basis, with multiple days in December, January, and February lacking the required RN coverage. Staff members reported challenges in providing adequate care due to insufficient staffing, and the DON acknowledged the issue, stating that they or the ADON would step in to assist when needed.
The facility failed to ensure proper labeling and storage of medications and biologicals, with observations revealing unlabeled and expired medications, loose pills, and improper storage practices in multiple medication carts and storage rooms. Staff interviews indicated a lack of awareness and adherence to protocols.
The facility failed to ensure that a resident was afforded the right to formulate an advance directive. Despite the resident's significant health issues, the facility did not follow its policy to provide information and document any existing directives. This deficiency was confirmed when the DON was unable to locate any advance directive for the resident.
The facility failed to ensure that a resident or his personal representative received discharge notification in writing and in a language they could understand upon discharge to the hospital. Additionally, the facility did not ensure that the state Ombudsman received a copy of the notification in a timely manner. The resident had multiple diagnoses and was hospitalized for several days. The Director of Nursing confirmed the lack of proper documentation in the medical record and incomplete information provided to the Ombudsman.
The facility failed to implement fall prevention interventions for a resident at risk for falls due to multiple medical conditions. Observations revealed improperly positioned fall mats, which were confirmed by an LPN and the DON. Despite the care plan and facility policies emphasizing proper placement of assistive devices, the facility did not ensure adherence, leading to a deficiency in care.
The facility failed to provide adequate nail care, maintain personal hygiene, and offer showers to a resident requiring extensive assistance with ADLs. Observations and interviews revealed that the resident had long, dirty fingernails and significant facial hair, and was not regularly offered showers. Staff inconsistencies in providing and documenting ADL care contributed to the deficiency.
A resident with multiple diagnoses, including osteomyelitis and wound botulism, received improper wound care from an LPN, who failed to follow the facility's wound care procedures. The LPN did not cleanse the wound correctly, used the same gauze for different areas, and did not change gloves appropriately, potentially compromising the resident's healing and increasing infection risk.
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in an 8 percent error rate. Insulin was administered incorrectly to two residents due to improper priming and administration techniques by LPNs.
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.
Deficient Food Storage, Equipment Cleanliness, and Sanitation in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's dietary services, including improper food storage, unclean equipment, and unsanitary practices. During kitchen tours, food items such as gravy, roast beef, opened cheese, and sliced sandwich meats were found in the refrigerator without labels or dates. Large bins containing sugar and flour had Styrofoam cups in direct contact with the food, rather than proper scoops. Additionally, dirty trays were stored on a rack in the prep area, and crumbs and scraps of paper were found on the floor. The oven's cooktop and sides were coated with thick grease and food debris, indicating a lack of regular cleaning. Interviews with dietary staff revealed a lack of awareness regarding the use of Styrofoam cups as scoops and confirmed that proper procedures for labeling, dating, and cleaning were not followed. The Dietary Manager acknowledged that staff should have labeled and dated food, that Styrofoam cups should not be used in dry food bins, and that the oven should have been cleaned. The facility was unable to provide a kitchen cleaning and service policy when requested by surveyors. These deficiencies had the potential to affect a significant number of residents who received meals prepared in the facility.
Failure to Implement Therapy Recommendations for Hand Splints in Residents with Contractures
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for the use of hand splints for three residents with contractures. For one resident with cerebral palsy and quadriplegia, the OT discharge summary recommended use of a left hand splint for three hours daily to prevent worsening contractures. However, there were no corresponding orders or care plan updates in the electronic medical record (EMR), and the resident reported that after therapy services ended, no one assisted with applying the splint, which was observed unused in the room. Another resident with a right hand contracture had OT recommendations for continued use of a right hand splint, but the care plan did not address this intervention, and no orders or treatments were found in the EMR. Observations showed the resident's hand contracted and the splint not in use, with staff interviews confirming a lack of follow-through on therapy recommendations after discharge from rehabilitation services. The Director of Nursing (DON) and Rehabilitation Director acknowledged communication failures between nursing and therapy regarding the implementation of splinting orders. A third resident with a right hand contracture and severe cognitive impairment had a physician order and care plan interventions for daily splinting, but observations revealed the resident was not wearing a splint, and staff were unaware of the need. The occupational therapist confirmed the resident should have a palm guard, but it was not found in the room, and staff reported using a towel instead. Interviews with facility leadership confirmed gaps in documentation, communication, and implementation of splinting interventions as recommended by therapy.
Failure to Ensure Resident Dignity and Privacy During Meal Service and Medication Administration
Penalty
Summary
The facility failed to promote residents' rights to dignity and privacy in two key areas. For 128 out of 147 residents, meals were served in Styrofoam containers during breakfast and lunch on two consecutive days. This occurred because the kitchen staff arrived to find dirty pots, pans, and dishes from the previous evening and did not have sufficient time to clean them before meal service. The Dietary Manager confirmed that serving meals in Styrofoam containers was not acceptable and that the kitchen should have been properly cleaned and prepared by the previous shift. The facility's policy on resident rights, which was undated, states that residents are to be protected and promoted in their rights, including privacy and dignity. Additionally, a resident with a history of congestive heart failure and neuromuscular dysfunction of the bladder, who was cognitively intact, did not have their right to physical privacy protected during medication administration. An LPN administered insulin and performed a suprapubic catheter irrigation with the resident's door left wide open and the privacy curtain not drawn, making the resident visible from the hallway. The LPN stated the door was left open to monitor an unlocked medication cart and laptop, but acknowledged that normally the privacy curtain would be used. Both the RN and DON confirmed that staff are expected to always provide privacy during patient care, with no exceptions.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents' ability to self-administer medications and did not follow its own policy regarding medication administration. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, a medication cup containing eight medications was left unattended on the overbed table. The resident, who was cognitively intact per a recent BIMS assessment, stated she had fallen asleep and forgot to take the medications, and then proceeded to take them after being prompted. The LPN confirmed she had left the medications and had not observed the resident taking them, and also acknowledged that the resident had not been assessed for self-administration, which was not in line with facility policy. Another cognitively intact resident with a history of congestive heart failure was observed to have a medicine cup with 13 pills left on the bedside table by an LPN, who stated that the resident preferred to take medications with breakfast and that she would return to check if the medications were taken. The resident also had a bottle of Tums at the bedside, which he reported purchasing himself and using as needed, and stated that the physician had seen the bottle but had not commented. The LPN and RN both confirmed that there was no assessment for self-administration for this resident, and that facility policy did not allow medications to be left at the bedside. Facility policy required that residents may self-administer medications only after an assessment by the Interdisciplinary Care Team, but neither resident had such an assessment or order in place. Staff interviews confirmed that medications were not to be left unattended and that there were no residents currently assessed to self-administer medications. The facility also reported that some residents order their own over-the-counter medications, which staff monitor and remove as needed. These actions and inactions resulted in a failure to assess and authorize self-administration of medications, contrary to facility policy and regulatory requirements.
Improper Disposal of Kitchen Garbage
Penalty
Summary
During an initial kitchen tour with the dietary cook, surveyors observed that the garbage container near the food preparation area was uncovered and overflowing, with additional garbage such as paper towels and gloves scattered on the floor. This unsanitary condition was directly observed in the kitchen, where meals are prepared for residents. In a subsequent interview, the Dietary Manager acknowledged that the situation was unacceptable and confirmed that garbage should be contained or emptied before reaching an overflowing state. The deficiency was limited to the improper disposal and containment of garbage in the kitchen area, as evidenced by the overflowing container and waste on the floor, with no mention of specific residents' medical histories or conditions at the time of the deficiency.
Improper Handling of Soiled Linen by Staff
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to properly handle soiled linen after providing activities of daily living (ADL) care to a resident. The LPN exited the resident's room carrying a large bundle of unbagged soiled linen and placed it in the laundry cart located 60 to 75 feet away from the room. This action was in direct violation of the facility's policy, which requires soiled linen to be minimally handled and placed in a collection bag before being removed from a resident's room. The LPN confirmed during an interview that the linen was not bagged as required by facility procedures. The resident involved had been readmitted with diagnoses including a urinary tract infection (UTI) and dysphagia, and was on Enhanced Barrier Precautions due to an enteral feeding tube. Interviews with other staff, including a Certified Nurse Aide (CNA) and the Infection Preventionist (IP), confirmed that the facility's expectation and policy is for all soiled linen to be bagged prior to removal from a resident's room to prevent the spread of infection. The failure to follow this protocol was observed and acknowledged by staff.
Failure to Post Current Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post current nurse staffing information daily as required. On review of the 24-hour nurse staffing posting in the front lobby, the information displayed was dated three days prior to the date of review and did not reflect the current staffing levels. During interviews, both the Assistant Administrator and the Director of Nursing confirmed that the posting was outdated and acknowledged that the staffing data should be current, accurate, and updated daily.
Failure to Identify Missing Resident and Implement Emergency Protocols
Penalty
Summary
The facility failed to identify and acknowledge that a resident was missing, which led to a delay in implementing emergency protocols to locate the resident. The resident, who had moderate cognitive impairment and was at risk of elopement, was last seen sitting in his wheelchair on the front porch of the facility. Staff assumed the resident was visiting friends within the facility, and it was not until the resident missed his afternoon medications and dinner that staff realized he was missing. The facility did not report the resident as missing to the Administrator or the police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding the resident's whereabouts. The Medical Records Clerk discovered that the transport company had mistakenly taken the resident instead of the intended individual, but this information was not promptly communicated to the facility's leadership. The Central Supply Clerk, who was covering the receptionist's lunch break, noticed transport vans but did not see anyone board them. The LPN on duty did not receive a report or notice anything unusual until a CNA mentioned the resident's untouched dinner tray. The Director of Nursing and Assistant Director of Nursing were unaware of the resident's absence until later in the day. The resident was eventually found at a local Waffle House, where he had informed workers that he wanted to go home. The police were contacted, and the resident was returned to the facility. Interviews with the Administrator and Social Services Director revealed confusion regarding the resident's decision-making capacity, as there was conflicting information in the medical records.
Removal Plan
- Resident #1 left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident #1 is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for.
- Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch
- Re-education for staff on Abuse, Neglect, or Mistreatment
- Re-education for staff on physically checking on residents at least every two hours
- Continue a midnight census every night as a daily audit.
- Safe area (courtyard) provided for residents to socialize. Residents informed.
- Adhoc QAPI
- ADON/designee will audit midnight census five times weekly x4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R3, who successfully eloped from the facility. R3, who had been admitted with diagnoses including depression, cognitive communication deficit, and unspecified psychosis, had a BIMS score indicating moderate cognitive impairment. On the day of the incident, R3 was last seen sitting in his wheelchair on the front porch after lunch, which was his usual routine. However, R3 was not available for his afternoon medications or dinner, and staff assumed he was visiting friends within the facility. The facility did not report R3 as potentially missing to the Administrator or the Police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding R3's whereabouts. The Medical Records Clerk noted a discrepancy with the transport company, which had mistakenly taken R3 instead of the intended resident. The Central Supply Clerk, covering the Receptionist's lunch break, observed transport vans but did not see anyone board them. LPN1, who was on duty, did not receive a report and was unaware of R3's absence until a CNA noted R3's untouched dinner tray. The DON confirmed that R3 left with transport instead of the intended resident, and a Code White was not initiated as it was not known that a resident was missing. The Administrator was not informed of the incident until the following day when R3 was returned to the facility by police after being found at a local Waffle House. The Administrator expressed that had she been aware of the situation, she would have initiated a lockdown and conducted a headcount. The SSD admitted to a lack of documentation regarding R3's decisional making capacity, contributing to the confusion in R3's medical record. The facility's failure to adhere to its elopement policy and ensure proper supervision and communication led to the resident's elopement.
Removal Plan
- Resident left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when resident returned to the facility. All residents were accounted for.
- Elopement drill conducted.
- Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch.
- Re-education for staff on Elopement Policy and Process and Abuse, Neglect, or Mistreatment.
- Elopement risk assessments completed on residents who reside in the facility.
- A review of residents who are assessed as an elopement risk was completed and care plans updated as appropriate.
- Safe area (courtyard) provided for residents to socialize. Residents informed.
- Adhoc QAPI.
- Continue a midnight census every night as a daily audit.
- ADON/designee will audit for elopement assessments completed and accurate within 24 hours or admission/readmission five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
- ADON/designee will audit 24-hour report and new nurses' notes (facility activity report) for documentation of elopement risks five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
- Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.
Smoking Safety Protocols and Assessments Deficiency
Penalty
Summary
The facility failed to conduct smoking assessments for 4 out of 10 residents who smoke and did not provide proper safety protocols for all 10 residents who smoke. During observations, it was noted that residents were smoking across the street from the facility without proper supervision or safety equipment. Interviews with residents revealed that they were crossing a busy street to smoke, expressing concerns about the lack of safety in doing so. Some residents mentioned keeping smoking materials on their person at all times, indicating a potential hazard. The facility's policy stated that smoking materials should be stored in assigned lockers, but this was not being enforced or monitored effectively. Review of individual residents' medical records highlighted specific risks and conditions that made smoking without proper supervision particularly hazardous. For example, Resident R80 had diagnoses including acute respiratory disease and COPD, while Resident R133 had chronic bronchitis and was identified as an unsafe smoker due to respiratory distress risk. These medical conditions, combined with the lack of proper smoking assessments and safety protocols, increased the potential for accidents and harm to these residents. The failure to address these risks in a timely manner contributed to the deficiency identified during the survey. Interviews with staff members revealed a lack of awareness regarding the smoking assessments and safety protocols for residents who smoke. Staff mentioned that residents were required to sign out to smoke but were not consistently monitored or supervised during this time. The facility's leadership acknowledged that they were not fully aware of the extent of residents smoking or the potential hazards associated with it. This lack of oversight and enforcement of smoking policies, combined with residents' behaviors and medical conditions, created an environment where accidents and safety risks were not adequately addressed.
Failure to Provide Clean Linens and Washcloths
Penalty
Summary
The facility failed to provide clean linen and washcloths to residents throughout the facility. This deficiency was identified through interviews, record reviews, and multiple observations. The Resident Council Meeting Minutes from September 2023 to February 2024 consistently revealed concerns about the lack of linens and washcloths. Observations on 03/12/24 and 03/13/24 showed that several rooms had stained, dirty, or soiled linens, and some beds had no linens at all. Residents were found lying directly on mattresses, and rooms had unpleasant odors, indicating a severe lapse in maintaining a clean and comfortable environment for the residents. During the Resident Council Meeting on 03/13/2024, residents expressed their frustration over the ongoing issue of linen shortages, stating that the problem had been discussed at every meeting without resolution. The Director of Nursing (DON) acknowledged the issue, attributing it to the outsourced laundry service, which was not providing timely and complete returns of laundered items. The DON mentioned that the contract with the outsourced company would be terminated at the end of the month, and all laundry services would be conducted in-house starting 04/01/24. However, the deficiency persisted at the time of the survey, affecting the residents' right to a safe, clean, and comfortable environment.
Insufficient RN Staffing
Penalty
Summary
The facility failed to provide sufficient Registered Nurse (RN) staffing on a 24-hour basis to ensure all residents receive adequate care. The facility's policy requires RN coverage for at least eight consecutive hours, seven days a week. However, the review of the Staffing Daily Posting revealed multiple days in December 2023, January 2023, and February 2023 where the facility did not meet this requirement. Specifically, there were six days in December, nine days in January, and thirteen days in February without the required RN coverage. This deficiency was confirmed through observations, interviews, and record reviews conducted by the surveyors. During interviews, staff members, including a Certified Nurse Assistant (CNA) and a Licensed Practical Nurse (LPN), reported challenges in providing adequate care due to insufficient staffing. The CNA mentioned that the number of residents they care for depends on the number of staff call-ins, and they often have to team up to provide care. The LPN stated that they communicate residents' concerns during huddles and inform the RN or Director of Nursing (DON) in case of emergencies. The DON acknowledged the staffing issues and mentioned that they or the Assistant Director of Nursing (ADON) would step in to assist when there is no RN on duty. Despite these efforts, the facility did not consistently meet the required RN staffing levels, leading to the identified deficiency.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed in multiple medication administration carts and storage rooms. Specifically, medications were found without open dates, loose pills were present in medication carts and narcotic lockboxes, and expired medications and biologicals were not removed from storage areas. For instance, in the medication storage room on Hall 300, items such as an open Luer Lock Disposable syringe and a bag of IV caps not in original packaging were found. Additionally, the refrigerator contained an unlabeled syringe and the floor was dirty with spills. In the treatment supply room on Hall 300, several items were improperly stored or expired, including hydrogen peroxide stored in a box labeled for non-woven drain sponges and a urological catheter strap in an open package. Similarly, the central supply room on Hall 200 contained expired suture removal trays and an open pack of cotton tip wood applicators. Loose pills and unlabeled medication pens were also found in medication carts on Halls 100 and 400, with some items lacking open dates, making it impossible to determine their expiration. Interviews with staff, including LPNs and the Central Supply Clerk, revealed a lack of awareness and adherence to proper medication storage protocols. The Director of Nursing (DON) indicated that medication storage rooms are managed by unit managers and the Central Supply Clerk, with monthly checks, while medication carts are managed by the nursing staff. However, the observations indicated that these checks were not effectively ensuring compliance with proper storage and labeling practices, leading to the deficiencies noted in the report.
Failure to Ensure Resident's Right to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was afforded the right to formulate an advance directive. The facility's policy on advance directives outlines specific procedures to be followed upon a resident's admission, including providing information about advance directives, obtaining signatures, and documenting any existing directives in the resident's medical and financial records. However, a review of R30's electronic medical record revealed no documentation of advance directives or any indication that R30 or his personal representative was given the opportunity to formulate one. This deficiency was confirmed during an interview with the Director of Nursing, who was unable to locate any advance directive for R30. R30 was admitted to the facility with multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. Despite these significant health issues, the facility did not follow its own policy to ensure that R30's rights regarding advance directives were upheld. This oversight indicates a failure in the facility's admission process and documentation practices, directly impacting the resident's right to make informed decisions about their care.
Failure to Provide Discharge Notification
Penalty
Summary
The facility failed to ensure that a resident or his personal representative received discharge notification in writing and in a language they could understand upon discharge to the hospital. Additionally, the facility did not ensure that the state Ombudsman received a copy of the notification in a timely manner. This deficiency was identified during a review of the facility's policy, record reviews, and interviews. The facility's policy requires that residents and their representatives be notified of transfers or discharges in writing and in a language they understand, and that a copy of the notice be sent to the state Ombudsman. However, the review of the resident's electronic medical record revealed no documentation to confirm that these notifications were made. The resident in question had multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. The resident was hospitalized from March 2 to March 6, 2024. During an interview, the Director of Nursing confirmed that the medical record did not contain a copy of the transfer paperwork given to the resident or the resident's representative. The documentation provided to the Ombudsman was also incomplete, lacking specific resident information such as names and dates of discharge.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement the interventions outlined in the care plan for Resident 53, who was at risk for falls due to multiple medical conditions including encephalopathy, seizures, and impaired mobility. The care plan specified the use of fall mats and ensuring the call light was within reach. However, during observations, the fall mats were found to be improperly positioned, with one mat diagonally under the bed and the other near the wall with a folding chair on top of it. This improper placement of fall mats was confirmed by both an LPN and the Director of Nursing (DON), who acknowledged that the mats should be beside the bed and the call light within reach to prevent falls. The DON also mentioned that Resident 53 sometimes places herself on the floor, which is noted in the care plan, but the expectation is that staff adhere to the care plan to keep the resident free from falls. The deficiency was identified through a review of the facility's policies and Resident 53's care plan, as well as direct observations and staff interviews. The facility's policies on care planning and fall management emphasize the need for individualized interventions and proper placement of assistive devices to prevent falls. Despite these policies, the facility did not ensure that the fall mats were correctly positioned, thereby failing to meet the professional standards of quality care as outlined in their own policies. This lapse in care was observed on multiple occasions, indicating a systemic issue in adhering to the care plan for Resident 53.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate nail care, maintain personal hygiene, and offer showers to a resident requiring extensive assistance with Activities of Daily Living (ADLs). The facility's policy mandates that necessary care be provided to all residents unable to perform ADLs independently. However, observations and interviews revealed that Resident 44, who has severe cognitive impairment and multiple medical conditions, did not receive proper nail care or regular showers. The resident's ADL Point of Care history indicated that he was only given a bath on eight out of twenty-nine days, with no option for a shower on seven of those days. Observations showed that the resident had long, dirty fingernails and significant facial hair, which he expressed dissatisfaction with during an interview. He also mentioned not being provided with a razor to shave his face and not being offered a shower. Interviews with staff members, including CNAs and LPNs, revealed inconsistencies in the provision and documentation of ADL care. CNA2 admitted to not providing any showers on the day of the interview and was unable to locate the documentation book for showers. CNA3 mentioned needing to ask a nurse before cutting the nails of diabetic residents, while LPN5 stated that personal hygiene tasks should be checked and addressed during morning care. The Director of Nursing (DON) confirmed that residents should be cleaned daily and that ADL care should include nail and personal hygiene. The DON also mentioned that showers should follow a schedule, but there was no documentation to indicate whether residents received a bed bath or a shower. Further interviews with other staff members, including CNA4 and LPN1, highlighted that personal hygiene care should be documented daily and that showers are typically provided between 8 am and 11 am. The Administrator confirmed that ADL care is provided throughout the day and that staff are educated on ADL care during orientation and ongoing training. However, the Administrator was only recently made aware that residents were not being offered showers according to their preferences. The lack of proper documentation and adherence to ADL care protocols led to the deficiency in providing adequate care for Resident 44.
Improper Wound Care Procedures
Penalty
Summary
The facility failed to follow proper wound care procedures for a resident, identified as R85, who was admitted with diagnoses including osteomyelitis of the vertebra, sacral and sacrococcygeal region, protein-calorie malnutrition, and wound botulism. During an observation of wound care performed by an LPN with a CNA assisting, several procedural errors were noted. The LPN did not cleanse the wound in a circular motion as required, used the same gauze to blot both the wound bed and the surrounding tissue, and did not change gloves appropriately between tasks. Additionally, the soiled dressing was saturated and not dated or initialed, and the bed beneath the chux was also saturated and stained with drainage, indicating improper wound management and infection control practices. The LPN confirmed during an interview that she had not correctly performed the wound care, acknowledging the improper use of gauze and gloves. The facility's policy on wound care states that pressure ulcers should be treated in accordance with professional standards to promote healing and prevent infection. However, the observed actions did not align with these standards, potentially compromising the resident's wound healing process and increasing the risk of infection.
Medication Administration Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in an 8 percent error rate. Specifically, insulin administered via an insulin pen was primed incorrectly and administered incorrectly for Resident 100. The Licensed Practical Nurse (LPN) held the pen horizontally and did not confirm the insulin escaping the needle. Additionally, the LPN did not hold the pen in the resident's skin for the required 10 seconds after pressing the dose button, removing it within 3 to 4 seconds instead. During an interview, the LPN confirmed the incorrect priming method and claimed to have counted to 10 before removing the needle, which was not observed to be true. Another instance involved LPN3 preparing to administer insulin to Resident 14. LPN3 also primed the insulin pen incorrectly by holding it horizontally and could not confirm that insulin had escaped the needle before administration. These actions led to the facility failing to meet the required medication administration error rate, as the incorrect priming and administration of insulin were observed in 2 out of 25 opportunities for error.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
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