St George Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint George, South Carolina.
- Location
- 905 Duke Street, Saint George, South Carolina 29477
- CMS Provider Number
- 425143
- Inspections on file
- 22
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St George Healthcare Center during CMS and state inspections, most recent first.
Unclean kitchen equipment and storage areas were observed in the dietary department. A large manual can opener had dried, sticky residue on the blade and base, the oven and stove top spill pan had dried and burned food buildup, and four drawers storing serving utensils and adaptive eating items had dried substances and loose food debris. The DM confirmed the items were unclean and stated the drawers, oven, and spill pan should be cleaned weekly or as needed, while the can opener should be cleaned after each use.
Controlled substance shift-change counts were not properly verified and signed, and multiple medication carts had controlled meds stored in blister packs with punched, ripped, torn, or taped foil. An LPN, RN, and DON interviews confirmed missing signatures on narcotic count sheets and damaged packaging for meds such as chlordiazepoxide, oxycodone, tramadol, lorazepam, and hydrocodone/APAP, with staff acknowledging the potential for drug diversion when seals were broken.
Failed Transmission of Annual MDS Assessment: A resident with type II DM, CKD, and altered mental status had an annual MDS signed as complete but marked Production Rejected and not transmitted to CMS. MDS staff confirmed the assessment was not sent, and the Administrator stated the facility expected timely MDS transmission but had no MDS policies, relying on the RAI Manual for procedures.
Staff competency for GT management was not validated before direct care was provided to a resident with a GT, dysphagia, GERD, and hospice status. An LPN attempted to flush the GT without first verifying placement by checking residuals, then left the room after the water would not infuse; later, the DON replaced the GT at bedside. Personnel files did not contain documentation of GT management or GT replacement training or competency validation for the LPN, DON, or ADON.
The facility failed to provide written notification of the reason for transfer or discharge to two residents and their representatives, as required by policy. One resident, cognitively intact, was admitted to the hospital with viral gastroenteritis and acute kidney injury, while another, moderately cognitively impaired, was admitted following syncope. Staff interviews revealed a misunderstanding of the requirement, with reliance on a bed hold notice instead of a written discharge notice.
The facility failed to provide complete Bed Hold notifications for two residents transferred to the hospital. One resident's notice was incomplete due to a missing daily rate, while the other resident's notice was not sent because there was no representative. Staff interviews revealed gaps in the notification process, with the Business Office Manager and Administrator acknowledging the deficiencies.
A resident with cognitive impairments and a history of wandering eloped from the facility due to inadequate supervision and lack of appropriate interventions in their care plan. Despite previous exit-seeking behavior, the resident did not have a wander guard, and the facility's cameras were not operational, complicating the investigation. The deficiency was related to the quality of care regulation.
Unclean kitchen equipment and storage areas
Penalty
Summary
The facility failed to keep the kitchen's large manual can opener, a kitchen oven, the stove top spill pan, and four kitchen drawers clean while they were stored and ready for use. During the initial kitchen inspection, the can opener was observed with dried and sticky substances on its blade and table base attachment, the oven had accumulated dried and burned food spills in its inner cooking compartment, the stove top spill pan had a heavy accumulation of dried food and burned food spills, and the inner storage compartments of four kitchen drawers had accumulated dried substances and loose food debris while holding serving scoops, serving spoons, spatulas, ladles, tongs, adaptive eating utensils, and measuring cups. The Dietary Manager was shown the unclean equipment and confirmed that the four kitchen drawers, kitchen oven, stove top spill pan, and the can opener's blade and table base attachment were unclean. During interview, the Dietary Manager stated the kitchen drawers, oven, and stove top spill pan should be cleaned weekly or as needed, and that the large manual can opener and its table base attachment should be cleaned after each use. The facility policy titled Sanitation & Food Safety in Food and Nutrition Services stated that the Certified Dietary Manager is responsible for food safety and sanitation, that infection control and sanitation practices are followed to minimize contamination, and that the CDM monitors food safety and sanitation daily and develops, implements, and monitors a cleaning schedule.
Controlled Substance Counts Not Signed and Blister Packs Found Damaged
Penalty
Summary
The facility failed to implement processes to ensure that controlled substance counts were verified and signed at each shift change and that controlled medications were maintained in a safe and secure manner. Review of the facility policy on controlled substances showed that a scheduled reconciliation of controlled substance inventory was to be completed at every nursing shift change and documented by both the off-going and oncoming staff members. The report identified this deficient practice in four of four medication carts observed on two units. On the [NAME] Unit, Medication Cart #1 had a missing signature from the oncoming LPN on the controlled substance shift change sheet. During the controlled drug count, multiple blister cards containing controlled substances were found with punched, ripped, torn, or taped foil on the back of the card, including chlordiazepoxide 25 mg capsules, oxycodone IR 5 mg tablets, tramadol 50 mg tablets, and lorazepam 0.5 mg tablets. The LPN stated she was required to sign the inventory count sheet after the narcotics were counted and said the exposed pills could be less effective, could fall out, or someone could take them for personal use. On the [NAME] Unit, Medication Cart #2 also had a missing oncoming nurse signature on the shift change sheet, and controlled substance blister cards were found with punched, ripped, torn, or taped foil, including hydrocodone/APAP 5/325 mg tablets and tramadol 50 mg tablets. On Stone Unit, Medication Cart #1 had a missing oncoming nurse signature and two tramadol blister cards with damaged foil, and Medication Cart #2 had three blister cards with damaged foil, including lorazepam 0.5 mg tablets and oxycodone/APAP 5/325 mg tablets. Staff interviews showed that one LPN forgot to sign the narcotic inventory sheet, another said she did not check the back of the cards when counting, and an RN stated that any broken seal was a risk of drug diversion. The DON stated that nurses and the Unit Manager were responsible for overseeing procedures that prevented drug diversion by monitoring the inventory log sheets and actual narcotic count.
Failed Transmission of Annual MDS Assessment
Penalty
Summary
The facility failed to ensure that an MDS assessment was transmitted to the State within the required timeframe for one resident. Review of the RAI Manual 3.0 showed that comprehensive assessments require completion of both the MDS and CAA process, and that the MDS completion date must be no later than 14 days from the ARD and no later than 14 days after the determination that criteria for an SCSA were met. The resident involved had an admission date of 04/24/23 and diagnoses that included type II diabetes mellitus, chronic kidney disease, and altered mental status. Review of the resident’s annual MDS with an ARD of 01/10/26 showed it was signed by an MDSC as completed on 01/16/26, but the assessment status was Production Rejected. The resident’s most recent successfully transmitted assessment was a quarterly MDS with an ARD of 10/10/25. During interviews, both MDSCs reviewed the annual MDS and confirmed it had not been transmitted to CMS. One MDSC stated she rejected the annual MDS and failed to transmit it, while the other MDSC stated she signed it as complete but did not know why it was rejected. The Administrator stated she expected MDS assessments to be transmitted on time and said the facility did not have MDS policies, using the RAI Manual for MDS procedures.
Staff Competency for GT Management Not Validated
Penalty
Summary
The facility failed to ensure nursing staff were competent in gastric tube (GT) management, including verifying tube placement before flushing and performing GT replacement, for one resident with a GT. The resident had diagnoses including dysphagia following cerebral infarction, gastroesophageal reflux disease without esophagitis, and gastrostomy status, and was receiving hospice services. The resident’s care plan directed staff to check placement and patency of the feeding tube before each feeding or medication administration, and the physician orders included checking residuals and flushing the tube with water before and after medication administration. During observation, an LPN disconnected the formula tubing from the resident’s GT feeding port and did not verify placement by checking gastric residual as ordered before attempting to flush the tube. The LPN poured approximately 30 cc of water into a syringe connected to the feeding port, but the water did not infuse, indicating the GT was not patent. The LPN then poured the water into a cup, detached the syringe, replaced the cap on the feeding port, and left the room. In a later interview, the LPN stated she had been told by the DON to use the syringe plunger to push the water through the GT and said she would verify tube placement by pushing air into the GT while listening with a stethoscope, which she said was the method she learned in school. Later the same day, the LPN again assessed the GT, withdrew gastric contents to check residual, returned the residual, and then poured approximately 30 cc of water into the syringe, which infused by gravity without difficulty after the DON had replaced the gastric tube. The DON confirmed he had replaced the resident’s GT and stated he had received training and been checked off for competence. Review of personnel files showed the LPN had competency validation only for isolation, handwashing, and perineal care, with no documentation of GT management or GT replacement training or competency. The DON’s file also lacked documentation of training or competency validation for gastric tube management or replacement, and the ADON’s file did not include documentation of training or competency validation for gastric tube management or replacement.
Failure to Provide Written Notification of Transfer Reasons
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to two residents, their representatives, and the ombudsman, as required by their policy. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy, revised on June 9, 2023, mandates that residents and their representatives be notified in writing and in a language and manner they understand. However, for two residents reviewed, there was no documentation of the reason for discharge provided in writing. Resident 58, who was cognitively intact with a BIMS score of 15, was admitted to the hospital with viral gastroenteritis and acute kidney injury on chronic kidney disease. Resident 70, who was moderately cognitively impaired with a BIMS score of 8, was admitted to the hospital following an episode of syncope. Interviews with the Social Services Director and the Director of Nurses revealed a misunderstanding of the requirement to provide written reasons for transfer or discharge, as they believed a bed hold notice sufficed. The Administrator was unaware of the lack of written discharge/transfer notices.
Incomplete Bed Hold Notifications for Hospital Transfers
Penalty
Summary
The facility failed to provide complete Bed Hold notifications to residents or their representatives upon discharge to the hospital for two residents reviewed for transfer and discharge. Resident 58, who was cognitively intact and required supervision for activities of daily living, was admitted to the hospital for viral gastroenteritis and acute kidney injury. The Bed Hold notice for Resident 58 was incomplete as it lacked the daily rate for the room charge. Resident 70, who was moderately cognitively impaired and also required supervision for activities of daily living, was admitted to the hospital following an episode of syncope. The Bed Hold notice for Resident 70 was not sent because the resident did not have a representative. Interviews with facility staff revealed that the Social Services Director sent a list of transfers and discharges to the ombudsman monthly, and the Business Office Manager was responsible for sending Bed Hold notifications to families and residents. However, the Business Office Manager admitted that the Bed Hold for Resident 58 was incomplete and that the notice for Resident 70 was not sent due to the absence of a resident representative. The Director of Nurses provided a checklist used during resident transfers, but it did not ensure the completion of Bed Hold notifications. The Administrator acknowledged the oversight in sending the Bed Hold notice for Resident 70 and the incomplete notice for Resident 58.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision for a resident, resulting in the resident successfully eloping from the facility. The resident, who was admitted with diagnoses including Huntington's disease, major depressive disorder, restlessness, agitation, and insomnia, was found to be severely impaired in cognitive skills for daily decision-making. Despite this, the resident's care plan did not include interventions related to wandering or elopement prior to the incident. An elopement risk observation conducted earlier had noted the resident's confusion and history of wandering, but no interventions were listed. On the day of the incident, a door alarm was triggered, and the resident was found outside in a company van. The resident was combative and had to be assisted back into the facility. Interviews with staff revealed that the resident had exhibited exit-seeking behavior in the past, but a wander guard was not in place at the time of the incident. The Director of Nursing was unaware of the resident's exit-seeking behavior, and the facility's cameras were not operational, which hindered the investigation. The facility's policy on elopement risk assessment required interventions to be added to the care plan after analyzing the information obtained, but this was not done for the resident in question. The lack of a wander guard and the failure to update the care plan with appropriate interventions contributed to the resident's ability to elope. The facility was notified of the immediate jeopardy status due to this deficiency, which was related to the quality of care regulation under 42 CFR 483.25.
Removal Plan
- Resident #1 without injury and elopement risk evaluation repeated with interventions in place per care plan.
- Director of Nursing and Administrator will be reeducated on the Elopement Policy and Process by the Clinical Consultant including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.
- Elopement risk Assessments will be reviewed for completion and accuracy by the Director of Nursing/Designee on current residents in facility to identify residents at risk for elopement. Those residents identified at risk will have interventions initiated and care plan updated.
- Licensed Nurses will be reeducated on the Elopement Policy and Process by the Director of Nursing/Designee including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.
- Licensed Nurses not receiving this education will receive prior to their next scheduled shift.
- Facility Activity Report and 24hour report will be reviewed in clinical morning meeting to validate elopement assessments completed. The Director of Nursing/Designee will review completed elopement assessments in clinical morning meeting to validate accuracy and interventions have been implemented accordingly.
- Ad hoc QAPI held.
- Medical Director was notified of the Immediate Jeopardy and the contents of this plan.
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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