St Andrews Operator, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, South Carolina.
- Location
- 3514 Sidney Road, Columbia, South Carolina 29210
- CMS Provider Number
- 425129
- Inspections on file
- 28
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at St Andrews Operator, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure proper storage, labeling, dating, and discarding of food items in the kitchen, with multiple opened and unsealed food items lacking required dates and labels, some stored on the floor or past expiration, and spoiled produce present. Despite facility policies and staff expectations for food safety, these deficiencies were observed during kitchen inspections.
The QAPI committee did not implement or sustain effective corrective actions for previously identified deficiencies, resulting in ongoing failures to label and date tube feeding bags, opened medications, and food items. These issues were observed again during follow-up, affecting all residents, despite the committee's belief that their audits were effective.
The facility did not maintain required infection surveillance documentation for 2024 and early 2025, as infection control records were missing after the previous ADON/infection preventionist left and took the data. As a result, there was no evidence of systematic infection tracking or reporting for that period, despite ongoing clinical meetings and antibiotic reviews.
Surveyors found expired and discontinued medications, as well as opened medications lacking required labeling, on multiple medication carts. An LPN confirmed the presence of an expired tube feeding formula, an opened insulin pen without an open or expiration date, and a loose unidentified pill. Additional expired and discontinued medications were found on other carts, with staff unsure of proper disposal procedures. The DON stated that nurses are responsible for disposing of such medications and that Unit Managers should audit carts weekly, but these procedures were not consistently followed.
A resident was readmitted with a sacral pressure ulcer that was not consistently documented in skin assessments or the MDS, despite being noted in initial assessments and provider communications. Nursing staff, without a dedicated wound care nurse, failed to accurately record the wound's presence, leading to incomplete and inaccurate documentation of the resident's condition.
A resident with multiple medical conditions, including a history of stroke, hyperglycemia, aphasia, and gastrostomy, was admitted with pressure and non-pressure areas but did not have a baseline care plan developed within 48 hours as required. The care plan was completed weeks later and failed to include the resident's tube feeding needs, as confirmed by the MDS Coordinator.
A resident with a gastrostomy and dysphagia did not receive the physician-ordered tube feed rate, as the feed was administered at 45 mL/hr instead of 50 mL/hr, and the feeding bag was not labeled or dated. Staff interviews revealed that the LPN did not verify the correct rate during shift change, contrary to facility policy requiring verification of tube feed orders.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
A cognitively impaired male with a history of behavioral disturbances repeatedly entered female residents' rooms and was found in the room of a non-verbal, dependent female, with reports of inappropriate touching. Despite prior documentation of unsafe behaviors and multiple staff and resident reports, the facility did not implement timely interventions or notify responsible parties, resulting in a failure to protect a vulnerable resident from non-consensual sexual contact.
A facility failed to promptly report and investigate an allegation of potential non-consensual sexual abuse involving two residents. Despite staff and resident reports of inappropriate behavior, management did not notify authorities, the resident's representative, or the Ombudsman in a timely manner. Documentation and interviews revealed incomplete assessments and a lack of thorough investigation, with staff being directed to follow administrative instructions rather than escalate the incident.
Water temperatures in several resident rooms and a shower room were found to be above the facility's policy limit of 120°F, with readings as high as 132°F. The Plant Operations Director increased water temperatures during the winter and did not reduce them after installing water boosters, resulting in excessively hot water. Staff noted the hot water, but no formal complaints were made by residents. The Facility Administrator was unaware of the temperature monitoring process, and the mixing valve was set above the facility's threshold, placing residents at risk for scalding.
Three cognitively intact residents were not treated with dignity or provided a sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a vulnerable resident. Despite facility policy requiring respect for resident well-being and privacy, staff failed to notify law enforcement or the responsible representative, did not send the affected resident for evaluation, and did not address ongoing concerns of retaliation and insecurity among residents.
A resident with severe cognitive impairment and behavioral disturbances was prescribed Depakote and later Seroquel for behavioral management, but the facility did not implement required monitoring for psychotropic medication use as outlined in its policy. This resulted in a lack of documented oversight for adverse effects and medication effectiveness during the period after Depakote was started.
The facility failed to follow its abuse prevention and investigation policies after two residents were involved in an alleged sexual abuse incident. Staff observed a male resident repeatedly entering female residents' rooms without consent, but the facility did not conduct a thorough investigation, notify law enforcement, or assess all potentially affected residents. Leadership did not interview other residents for safety concerns or implement additional interventions, resulting in inadequate protection and support for those involved.
Failure to Properly Store, Label, and Discard Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage, labeling, dating, and discarding of food items in the kitchen, including the freezer, refrigerator, and dry storage areas. During multiple observations, opened food items were found without open dates or use-by dates, and some were not properly sealed. Specific findings included boxes stored on the floor, opened bags and containers of food without required labeling, and food items past their manufacturer expiration dates. Additionally, some cans were covered with a white powdery substance, and rusted shelves were noted in the walk-in cooler. Perishable items such as cut onions and baby spinach were improperly labeled or visibly spoiled, and several containers of seasonings and other dry goods lacked open or use-by dates. Interviews with the Dietary Manager and Administrator confirmed that the facility's policy requires all food items to be labeled with the name, date of preparation or opening, and a use-by date, and that items past their expiration or use-by date should be discarded. The Dietary Manager stated that daily rounds are conducted in the kitchen, and the Administrator indicated that walkthroughs are performed weekly or monthly. Despite these stated expectations and policies, the observed deficiencies in food storage and labeling practices were not addressed, resulting in noncompliance with professional standards for food safety.
QAPI Committee Failed to Sustain Corrective Actions for Labeling and Storage Deficiencies
Penalty
Summary
The facility's QAPI committee failed to implement effective corrective actions to address previously identified deficiencies, as evidenced by ongoing issues with labeling and dating of tube feeding bags, medications, and food items. During a recertification and complaint survey, the facility was cited for not labeling and dating a tube feeding bag, not labeling opened medications, and not ensuring food was sealed, labeled, and dated with a use-by date. These deficiencies were observed again during follow-up, including an unlabeled tube feeding bag for a resident, opened vials of insulin on two medication carts without opened dates, and unsealed, unlabeled food items in the kitchen. Review of the facility's QAPI meeting minutes showed that while the committee discussed the plan of correction and audit tools, the only documentation was a copy of the CMS-2567 attached to the minutes. During an interview, the Administrator stated that the committee believed the audits were effective, but was unable to explain the continued presence of the same deficiencies. The lack of effective follow-through and sustained corrective action by the QAPI committee contributed to the ongoing noncompliance affecting all residents in the facility.
Failure to Maintain Infection Surveillance and Documentation
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program as required. Specifically, there was no documentation of a surveillance plan for tracking or monitoring infections, communicable diseases, and outbreaks among residents and staff for the entire year of 2024 and the months of January and February 2025. The facility's policy required routine monitoring and surveillance, including the use of standardized assessment tools and regular reporting to the QAPI committee. However, interviews revealed that the infection preventionist identified infections based on resident symptoms and physician input, but there was no evidence of systematic infection tracking or trending prior to April 2025. Further investigation found that the previous Assistant Director of Nursing, who also served as the infection preventionist, left the facility in March 2025 and took the infection control records with her. As a result, the facility was unable to produce any infection control data for the period before April 2025, despite attempts to retrieve the information. While clinical meetings and antibiotic reviews were conducted, and infection numbers were presented in QAPI meetings after April 2025, there was a lack of documented infection surveillance and reporting for the earlier period, constituting noncompliance with infection control requirements.
Failure to Remove Expired and Discontinued Medications and Properly Label Opened Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled, stored, and removed when expired or discontinued, as required by policy and professional standards. During observations of three medication carts, surveyors found an expired box of Nutren 2.0 tube feeding formula, an opened Novolog FlexPen injector without an open or expiration date, and an unidentified loose white pill. Additionally, opened bottles of Sorbitol 70% solution and Robitussin DM were found to be expired and had been previously discontinued. Nursing staff confirmed these findings and acknowledged that the required labeling and removal procedures had not been followed. Interviews revealed that nursing staff were either unaware of or did not follow proper procedures for labeling opened medications and disposing of expired or discontinued drugs. The DON stated that all nurses have the authority to dispose of such medications using a Drug Buster, which is available on each cart, and that Unit Managers are responsible for weekly audits to ensure expired medications are removed. However, the presence of expired, discontinued, and improperly labeled medications on multiple carts indicated a failure to consistently implement these procedures.
Failure to Accurately Document Pressure Ulcer on Assessment and MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of a pressure ulcer for one resident. Upon readmission, the resident returned with a sacral pressure ulcer, which was noted in the initial head-to-toe skin check and provider communication log. However, subsequent weekly skin assessments failed to document the presence of the wound, and the Minimum Data Set (MDS) assessment did not indicate the existence of a pressure ulcer, despite physician orders for wound care being in place. The MDS Coordinator relied on nursing documentation, which incorrectly showed the resident's skin as intact during the lookback period, leading to inaccurate reporting on the MDS. Interviews revealed that the facility did not have a dedicated wound care nurse, and wound care responsibilities were shared among nursing staff, with oversight from a wound care provider and nurse practitioner during weekly rounds. The Director of Nursing stated that unit managers are responsible for admission assessments, while floor nurses are expected to document ongoing skin issues. The deficiency resulted from incomplete and inaccurate documentation of the resident's pressure ulcer status in both the skin assessments and the MDS, despite clear evidence of the wound in other records.
Failure to Timely Develop Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by its own policy. The resident was admitted with a medical history including cerebral infarction, hyperglycemia, aphasia, and gastrostomy status, and presented with pressure areas on several parts of the body and non-pressure areas on the back and left ear. The baseline care plan was not completed until several weeks after admission and did not address the resident's need for tube feeding. The MDS Coordinator confirmed that the baseline care plan was delayed and incomplete, omitting necessary interventions for the resident's care during the initial period after admission.
Failure to Administer Ordered Tube Feed Rate and Label Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident receiving continuous tube feeding was administered the correct ordered amount and rate of tube feed, as well as failed to properly label and date the tube feed bag. Specifically, the resident, who had diagnoses including gastrostomy status, dysphagia, and adult failure to thrive, was observed to have their tube feed infusing at 45 mL/hr instead of the physician-ordered rate of 50 mL/hr. The facility's policy required verification of the enteral nutrition label against the order before administration, including documentation of the date, time, and initials on the formula label, but this was not followed. During multiple observations, the tube feed was found running at the incorrect rate and without a label or date. Interviews with staff revealed that the LPN did not verify the correct rate with the off-going nurse during shift change, and the Director of Nursing confirmed that both off-going and incoming nurses are required to check tube feed orders during shift changes. The resident's medical record and nutrition notes confirmed the prescribed feeding regimen, which was not adhered to during the observed period.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, but does not provide further details about the specific actions or inactions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A cognitively impaired male resident with a history of frontal lobe and executive function deficit, impulse disorder, and dementia with behavioral disturbances was documented to have repeatedly entered the rooms of female residents without consent. Despite prior documentation of his inappropriate and unsafe behaviors, including wandering, entering female residents' rooms, and being redirected multiple times, the facility did not implement timely or adequate interventions to prevent further incidents. On one occasion, the resident was found in the room of a non-interviewable, vegetative female resident, with staff and other residents reporting that he touched her inappropriately. Multiple staff and residents reported previous similar incidents, and concerns were raised about the lack of effective action to prevent recurrence. The female resident involved was in a vegetative state, fully dependent on staff for all activities of daily living, and unable to protect herself or report abuse. There was no documentation in her medical record related to the incident, and a required head-to-toe skin check assessment was left incomplete. The resident's representative was not informed of the incident by facility staff and only learned of it from another resident. Staff interviews revealed that some were instructed by administration to alter documentation to downplay the incident, and law enforcement was not notified. The male resident was sent to the hospital for evaluation but returned the same day and was placed back in proximity to the female resident. Multiple interviews with staff and residents confirmed that the male resident's behaviors were known and had been reported prior to the incident, but interventions such as room changes or increased supervision were not implemented in a timely manner. Staff expressed concerns that the facility did not take appropriate steps to protect vulnerable residents, failed to notify responsible parties, and did not follow abuse reporting protocols. The facility's inaction and lack of adequate interventions resulted in a failure to protect the female resident from a non-consensual sexual encounter.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of potential non-consensual sexual abuse involving two residents to the proper authorities and state agency within the required timeframes. According to the facility's own policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. In this case, a resident was observed entering another resident's room without consent, and there were reports from both staff and other residents of similar behavior. Despite these observations and reports, management was only notified for a possible room change, and there was no immediate notification to authorities or the resident's representative. Documentation in the electronic medical record showed that the resident who entered the room had a history of altered mental status and was redirected multiple times from female residents' rooms. Staff, including an LPN, reported concerns about the resident's sexually inappropriate behavior to the Administrator and DON, but were instructed to follow administrative directives rather than escalate the matter to law enforcement or ensure a thorough evaluation of the potentially affected resident. The resident's representative was not formally notified of the incident, and the facility did not complete a timely or thorough investigation, as evidenced by incomplete documentation of a head-to-toe skin check and lack of interviews with other potentially affected residents. Interviews with staff and the resident's representative revealed that law enforcement and the Ombudsman were not notified promptly, and the Medical Director was also not informed of the potential abuse. The facility administration failed to ensure that all required parties were notified, did not conduct comprehensive resident interviews or assessments to rule out further harm, and did not document or communicate the incident as required by policy and regulation. The deficiency was identified as Immediate Jeopardy due to the failure to report and investigate the allegation of sexual abuse in a timely and appropriate manner.
Unsafe Water Temperatures Exceeding Policy Limits
Penalty
Summary
The facility failed to maintain water temperatures within safe limits, as required by its own policy and federal guidelines, which state that tap water should not exceed 120°F to prevent scalding. During observations, water temperatures in multiple resident rooms and a shower room were found to be significantly above this threshold, with readings ranging from 122.1°F to 132°F. The Plant Operations Director (POD) acknowledged that the water was excessively hot and admitted to increasing the temperature during the winter in response to resident complaints about cold water. However, the temperatures were not reduced after the installation of water boosters, nor were they adjusted back to safe levels until after the surveyor's findings. Interviews with staff revealed that no formal resident complaints about hot water had been made, but an LPN noted that the sinks became very hot during handwashing. The Facility Administrator (FA) was unaware of the specific process used by the POD to check water temperatures and confirmed that the mixing valve had been set above the facility's threshold. The facility's failure to monitor and maintain water temperatures within the safe range placed residents at risk for scalding injuries in all three halls reviewed.
Failure to Maintain Resident Dignity and Safety After Reported Sexual Incident
Penalty
Summary
The facility failed to ensure that three cognitively intact residents were treated with dignity and maintained a sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a non-interviewable resident. The facility's policy requires that residents be cared for in a manner that promotes their well-being, self-worth, and respect for their private space, but this was not upheld. Multiple residents reported that a resident with a history of wandering and inappropriate behavior entered another resident's room, closed the door, and was found in a potentially sexually inappropriate situation. Staff were observed yelling at the resident to leave the room and calling for assistance, but there was no evidence that law enforcement or the responsible representative was notified, and the affected resident was not sent for evaluation. Residents who witnessed or reported the incident described feeling unsafe and expressed concerns about retaliation from staff. One resident reported being told by staff not to "spread false rumors" and to "shut my mouth," leading to fear about future care. Another resident, who was the roommate of the resident involved in the incident, stated that he avoided his room due to discomfort and observed staff being retaliative. This resident also described the resident in question bragging about the incident to others, with staff present but not intervening appropriately. A third resident reported that the same resident had previously attempted to enter her room and had entered the room of the vulnerable resident on multiple occasions, including at night. She stated that her reports to nursing staff were dismissed and that she did not feel safe, as the resident remained on the same hall and close to the affected resident. The lack of appropriate response to these reports and the ongoing proximity of the resident in question contributed to a continued sense of insecurity and lack of dignity among the residents involved.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring for the use of psychotropic medications for a resident with severe cognitive impairment and behavioral disturbances. The resident, who had diagnoses including dementia with behaviors, impulse disorder, and psychoactive substance dependence in remission, was prescribed Depakote and later Seroquel to manage behavioral symptoms. Despite facility policy requiring monitoring for efficacy and adverse consequences when psychotropic medications are used, there was no documented antipsychotic monitoring for the resident after Depakote was initiated. The care plan indicated that monitoring, including observation for side effects and the use of the Abnormal Involuntary Movement Scale (AIMS), should be conducted, but this was not implemented as required. Interviews with the consultant pharmacist, psychiatric nurse practitioner, and medical director confirmed that behavior and antipsychotic monitoring should have been in place when the resident began receiving Depakote. The lack of monitoring persisted until after Seroquel was started, leaving a gap in oversight for potential adverse effects and effectiveness of the psychotropic medication. This failure to follow established protocols for psychotropic medication management led to the identified deficiency.
Failure to Implement Abuse Prevention and Investigation Policies
Penalty
Summary
The facility failed to implement its abuse prevention and investigation policies in response to allegations of sexual abuse involving two residents. According to the facility's own policies, the administrator is responsible for ensuring prevention of further abuse, and investigators are required to interview all relevant staff, residents, and witnesses, as well as review all events leading up to the alleged incident. However, the facility did not conduct a thorough investigation, did not report the incident to law enforcement, and did not ensure that all potentially affected residents were interviewed or assessed. Documentation shows that a male resident repeatedly entered female residents' rooms without consent, and staff observed and redirected him on multiple occasions, but no comprehensive investigation or protective measures were implemented as required by policy. Nursing notes and staff interviews revealed that the male resident was seen entering a female resident's room while a CNA was providing care, and another female resident reported similar behavior the previous night. Staff educated the male resident about not entering other residents' rooms, but there was no documentation of assessment or follow-up for the female resident involved in the incident. Multiple staff members, including CNAs and LPNs, reported the male resident's inappropriate behavior and expressed concerns about the lack of action taken by facility leadership. The facility did not notify the resident representative, did not interview other potentially affected residents, and did not implement additional interventions after repeated incidents. Interviews with facility leadership, including the unit manager, assistant director of nursing, and facility administrator, confirmed that no residents were interviewed regarding safety concerns after the incident, and there was no clear plan to ensure resident safety. The administrator was unaware of the documented behavioral concerns prior to the incident, and staff reported being instructed not to contact law enforcement or send the female resident for evaluation. The facility's failure to follow its own abuse prevention and investigation policies resulted in a lack of protection and support for residents involved in or potentially affected by the alleged abuse.
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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