The Heritage At Lowman Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in White Rock, South Carolina.
- Location
- 201 Fortress Drive, White Rock, South Carolina 29177
- CMS Provider Number
- 425100
- Inspections on file
- 20
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Heritage At Lowman Rehab And Healthcare during CMS and state inspections, most recent first.
Surveyors found that nourishment room refrigerators on multiple units were not maintained within the facility’s required temperature range and that temperature logs were frequently incomplete or missing. In several units, recorded refrigerator temperatures were consistently above 40°F, and multiple days had no temperature documentation at all. One refrigerator lacked an internal thermometer. During interviews, leadership reported that kitchen staff are responsible for checking nourishment rooms, a supervisor aide reviews for expired items and logs, and the staff member currently assigned to these checks is new, while the Administrator stated that kitchen and nursing staff are expected to monitor temperatures and stocking with training provided during orientation and annually.
Surveyors found that nursing staff did not consistently follow the facility’s medication storage policy, resulting in expired and improperly stored medications on multiple medication carts. On one cart, an opened Insulin Aspart vial remained available for use past its expiration, and Promethegan suppositories labeled for refrigeration were stored at room temperature. On another cart, several Insulin Aspart FlexPens and a Liraglutide injection pen lacked required open dates or usable dating, and on a third cart, expired Alprazolam tablets remained in the drawer despite having been administered previously. These issues showed that outdated medications and undated insulin and injectable products were stored with medications in active use.
A resident with intact cognition and multiple medical conditions, including chronic respiratory failure and generalized muscle weakness, had a care plan directing staff to provide a daily shower/tub/bed bath and PRN, but facility records showed long periods with no documented baths or offers of bathing, particularly on weekends. The resident reported not receiving needed assistance, stated that a shower was expected on a specific day each week, and that no alternative baths were offered when that did not occur, nor were baths or showers offered on certain other days. Documentation did not show daily refusals, and the care plan did not address any refusal pattern. The Administrator and a CNA described expectations that residents be offered regular baths and that refusals be documented, highlighting that the resident’s bathing preferences and care plan were not consistently followed or recorded.
Surveyors found the facility’s medication error rate at 8%, exceeding the 5% threshold, due to improper insulin pen administration techniques by nursing staff. Policy and manufacturer instructions required priming insulin pens by dialing 2 units and holding the pen with the needle pointing upward until a drop of insulin appeared. Instead, an LPN primed a pen with the needle pointed downward into a trash can, and an RN primed a pen horizontally with the needle cap left on, without observing insulin at the needle tip. These deviations from required priming procedures contributed to the elevated medication error rate.
The facility failed to identify specific behaviors for antipsychotic use in a resident with dementia and did not ensure end dates for psychotropic medications for three residents. Interviews confirmed the lack of specific behavior monitoring and missing end dates for as-needed medications.
The facility failed to remove discontinued medications from medication carts, as observed during a survey. Medications for three residents were found in the carts without current physician orders. The facility's policy requires discontinued medications to be returned or destroyed, but they remained in the carts, confirmed by nursing staff. The Pharmacy Consultant and DON acknowledged the medications should have been removed and disposed of properly.
The facility failed to administer pneumonia vaccinations to three residents, despite its policy requiring all residents to be offered vaccines unless contraindicated or previously vaccinated. One resident had no documentation of consent or refusal for an updated vaccine, another consented but was not administered the vaccine, and a third had no further vaccinations documented after receiving PCV13 in 2015. The DON confirmed the lapse in vaccination administration.
A resident, who was cognitively intact, expressed a preference for regular dining ware instead of Styrofoam and plastic utensils during a COVID-19 outbreak. Despite not having COVID-19, the resident was subjected to the same restrictions as those in isolation, contrary to the facility's policy. The decision to use Styrofoam for all residents was made by the DON and Administrator, without considering individual preferences.
A resident was not involved in the care planning process as required by facility policy. Despite being cognitively intact, the resident was unaware of care plan meetings, with the last documented meeting occurring over a year ago. The Social Services Director acknowledged a review took place but failed to conduct a full meeting or document it in the EMR, leading to a deficiency.
A resident with dementia, congestive heart failure, and asthma was found with medications at their bedside without an assessment for self-administration. The facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. The resident was cognitively intact, but the medications were not ordered to be kept at the bedside, leading to potential risks.
The facility failed to ensure that the SNF-ABN was accurate and complete for two residents prior to their discharge from Medicare Part A skilled services. For one resident with Parkinson's disease and another with dementia, the section for selecting options regarding payment responsibility was left blank, leaving them uninformed about their choices and financial responsibilities. The Social Services Director admitted to being unaware of the requirement to document the estimated cost per day and acknowledged that the options box should have been checked.
The facility failed to create comprehensive care plans for behavioral symptoms for three residents, leading to unmet care needs. One resident exhibited disruptive behavior without a care plan addressing it, despite being prescribed medications. Another resident's care plan only addressed medication side effects, not the behaviors leading to prescriptions. A third resident exhibited various disruptive behaviors, but the care plan lacked interventions for these symptoms. Staff interviews revealed unclear responsibilities for care planning.
A resident's care plan inaccurately included diabetic interventions, despite the resident not having diabetes. The resident, who had severe cognitive impairment and was receiving hospice care, was at risk of unmet care needs due to this error. The Registered Dietician confirmed the inaccuracy and was unsure why these interventions were included.
A resident with a history of pressure ulcers did not have their heels elevated as ordered, despite being at risk for skin integrity issues. Observations showed the resident's feet were not elevated, and staff interviews revealed a lack of awareness about the care plan requirements.
A facility failed to implement orders for a splint/palm protector for a resident with limited ROM, leading to potential further decrease of ROM and/or pain. The resident, with severe cognitive impairment and multiple diagnoses, was observed without the prescribed device. Staff interviews revealed confusion and inconsistency regarding the device's application, and the Treatment Administration Record showed no documentation of its use.
A facility failed to properly store oxygen tanks, creating potential hazards. An oxygen tank was found free-standing in a resident's room, despite the presence of a holder. Additionally, a tank was improperly stored in a storage room. Staff interviews confirmed the facility's policy required secure storage of oxygen tanks, which was not followed.
The facility failed to maintain proper nutritional care for three residents, leading to significant weight changes and inadequate meal monitoring. One resident experienced substantial weight loss without proper intervention, while another faced inconsistent meal documentation and weight fluctuations. A third resident's weight was inaccurately monitored, contributing to the deficiency. The Registered Dietitian acknowledged issues with weight accuracy and incomplete meal records, impacting nutritional assessments.
A facility failed to monitor the prophylactic use of an antibiotic for a resident with a history of UTIs, leading to a deficiency in antibiotic stewardship. The resident was on Nitrofurantoin daily, but the care plan did not address its use, and there was no documentation of symptom monitoring. Despite a letter from the Pharmacy Consultant, the physician continued the regimen without providing a rationale, placing the resident at risk.
A resident fell and sustained multiple injuries, including fractures and hematomas, when staff providing incontinent care walked away, leaving the resident unsupported. The resident had a significant medical history and was dependent on staff for all activities of daily living.
Failure to Maintain Safe Temperatures and Monitoring in Nourishment Room Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe refrigerator temperatures and complete temperature monitoring in all four nourishment room refrigerators, contrary to its own policy titled "Refrigerators and Freezers" revised December 2022. The policy requires refrigerator temperatures to be maintained between 35°F and 40°F, freezers at less than 0°F, and mandates monthly tracking sheets for all refrigerators and freezers with documentation of corrective actions when temperatures are out of range. Review of the December 2025 temperature log for the Damascus unit nourishment room refrigerator showed that all six recorded temperatures were above 40°F, and no data was recorded for days 7 through 9. In addition, an observation of the Damascus unit nourishment room refrigerator revealed there was no thermometer present to measure the internal temperature. Similar issues were identified in the nourishment room refrigerators on the Bethal and two other named units. For the Bethal unit, the September 2025 temperature log had no data recorded for days 28 through 30, and the December 2025 log showed two of four recorded temperatures above 40°F with no data recorded for days 5 through 9. For one unit, the September 2025 log had no data for days 26 through 30, and the December 2025 log showed three of four recorded temperatures above 40°F with no data for days 5 through 9. For another unit, the September 2025 log had no data for days 19 through 20 and 23 through 30, and the December 2025 log showed four of four recorded temperatures above 40°F with no data for days 5 through 9. During interviews, the Culinary Manager and Registered Dietician stated that kitchen staff are responsible for checking nourishment rooms on each unit, and a supervisor aide checks behind them for expired items and temperature logs, noting that the person currently assigned to check the nourishment areas is new. The Administrator stated her expectation that kitchen staff assist with monitoring nourishment room temperatures and stocking, with nursing staff helping, and that training is provided during orientation, annually, and as needed.
Expired and Improperly Stored Medications on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored and labeled according to policy and professional standards, including removal of outdated/expired medications and proper storage conditions. The facility policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner, with nursing staff responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and for refrigerating unopened insulin vials/pens until use and dating them once opened. During an observation of Medication Cart A on one wing, surveyors found an Insulin Aspart Injection vial that had been opened on 11/04/25 and was expired as of 12/02/25, yet remained on the cart. They also found a ten-count package of Promethegan 25 mg suppositories labeled to be refrigerated, stored in the top drawer of the cart and not cool to the touch. Further observations of Medication Cart A on another wing revealed multiple insulin and injectable medications without required open dates or clear usable dating. An Insulin Aspart FlexPen had a manufacturer expiration date of 10/08/25 but no open date documented. A Liraglutide Injection pen and another Insulin Aspart FlexPen were also present without any open dates or expiration dates noted on them. On Medication Cart B, surveyors identified Alprazolam 0.25 mg tablets with an expiration date of 07/2025 still stored on the cart, with four tablets remaining, and documentation showing the medication was last administered on 11/21/25. These findings showed that expired medications and medications lacking required dating were stored on active medication carts alongside medications in current use, contrary to the facility’s own storage policy.
Failure to Honor Resident Bathing Preferences and Provide Daily Bathing as Care Planned
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s stated bathing preferences and to provide or offer daily bathing assistance as care planned. Facility policy on Resident Shower and Bathing requires that residents receive assistance for bathing and showering in accordance with their care plans, with personal hygiene needs met and preferences honored. The resident was admitted with multiple diagnoses including pulmonary edema, chronic respiratory failure with hypoxia, lack of coordination, central corneal ulcer, and generalized muscle weakness. A recent MDS showed a BIMS score of 15/15, indicating intact decision-making ability. The resident’s comprehensive care plan identified a self-care deficit related to osteoporosis, unsteadiness, generalized muscle weakness, gait abnormalities, and pre-glaucoma, with a goal that the resident would be neat, clean, and dressed daily, and an intervention directing staff to complete a shower/tub/bed bath daily and PRN. The care plan did not document any pattern of bathing refusals. Despite this, review of shower and bath documentation showed that the resident was not offered and did not receive any type of bath on Fridays, Saturdays, and Sundays in August and September, had only two days of documented baths or offers in October, and only six days of any type of bath documented in November. There was no documentation that the resident refused daily baths or showers. The resident reported not receiving needed assistance to bathe, stated that Fridays were her preferred shower day and that if she did not get a shower on Fridays no other type of bath was offered, and that she was told she was not on the list when she requested bathing on Saturdays, with no baths or showers offered on Sundays. She also stated that most days she was not offered any type of bath and that it depended on which staff were working. The Administrator acknowledged that refusals were marked on the report but that many of the notations reflected that the resident had already received a bath that day, and the surveyor noted concern about days with no documentation of an offer or provision of bathing. A CNA stated that residents are supposed to receive bed baths seven days a week and showers two days a week, and that refusals must be offered and documented, underscoring that the expected practice was not consistently followed for this resident.
Improper Insulin Pen Priming Leading to Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in an 8% error rate based on 2 errors out of 25 opportunities. Facility policy on insulin pens required staff to follow proper infection control, storage, administration, and documentation practices, including specific steps for priming the pen: dialing 2 units, holding the pen with the needle pointing upward, tapping to move air bubbles to the top, and pressing the injection button until insulin appeared at the tip, with instructions to discard the pen and notify the nurse/pharmacy if insulin did not appear after 3–4 attempts. The manufacturer’s recommendations similarly directed staff to wipe the pen tip with alcohol, attach the needle, remove both caps, dial 2 units, hold the pen with the needle pointing upwards, and press the button until at least one drop of insulin appeared, repeating as needed before dialing the ordered dose. During one observed insulin administration, an LPN primed an insulin pen while holding it with the needle pointed downward into a trash can, contrary to both facility policy and manufacturer instructions that required the needle to be pointed upward. In a separate observation, an RN attempted to prime an insulin pen while holding it horizontally and leaving the cap on the needle, then dialed 2 units and pushed the dosage button without seeing insulin escape the needle. The RN confirmed priming the pen horizontally with the needle capped and stated this was her usual practice. These observed practices deviated from the required priming procedures and contributed to the calculated medication error rate of 8%.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to identify specific trigger behaviors for the use of antipsychotic medication in one resident, who was admitted with Parkinson's disease and dementia. This resident was severely cognitively impaired and was administered antipsychotic medication daily without documented specific behaviors being monitored. Interviews with the LPN, DON, and SSD confirmed that while behavior monitoring was noted, no specific behaviors were identified or documented for this resident. Additionally, the facility did not ensure that psychotropic medications had an end date for three residents. These residents were prescribed medications such as Lorazepam and Clonazepam for conditions like anxiety disorder, altered mental status, and dementia, but the orders lacked specified end dates. The Pharmacy Consultant and DON confirmed the necessity of having end dates for as-needed psychotropic medications, which were missing in these cases.
Failure to Remove Discontinued Medications from Carts
Penalty
Summary
The facility failed to ensure that discontinued medications were removed from medication carts, as observed during a survey. Specifically, medications for three residents were found in the medication carts without current physician orders. For one resident, dronabinol and oxycodone were found in the narcotic drawer of the medication cart, despite the orders for these medications having ended on specific dates in August. Another resident had alprazolam in the medication cart, with the order having ended in February. A third resident had hydrocodone-acetaminophen and tramadol in the cart, with orders that ended in May and June, respectively. The facility's policy requires that discontinued, outdated, or deteriorated medications be returned or destroyed as per the dispensing pharmacy's instructions. However, the medications remained in the carts, which was confirmed by the nursing staff during observations. The Pharmacy Consultant and the Director of Nursing acknowledged that the medications should have been removed and disposed of properly once the orders ended. The process outlined by the Director of Nursing involves notifying the unit manager, who, along with the nurse, would log and secure the medications until disposal by the pharmacy.
Failure to Administer Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure pneumonia vaccinations were offered and/or provided to three of five residents reviewed for immunizations. The facility's policy, dated April 2023, mandates that all residents be offered vaccines to prevent infectious diseases unless contraindicated or previously vaccinated. However, the review revealed that Resident 25, who was admitted on an unspecified date and had received PCV 13 in 2016 and PPSV 23 in 2005, had no documentation of an up-to-date pneumonia vaccine consent or refusal as of June 2024. Similarly, Resident 43, admitted on an unspecified date, had received PPSV 23 in 2022 but had not been administered the updated pneumonia vaccine despite consenting in May 2023. Resident 100, admitted on an unspecified date, had received the PCV13 vaccine in 2015, with no further documentation of pneumonia vaccinations. The admission Vaccination Consent Form for Resident 100, dated December 2023, did not indicate whether the resident consented to or refused the pneumonia vaccine. During an interview, the DON, who had been in the position for three weeks, confirmed that the pneumonia vaccines were not administered, highlighting a lapse in the facility's adherence to its vaccination policy.
Failure to Honor Resident's Dining Preferences During COVID-19 Outbreak
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding the use of regular dining ware during a COVID-19 outbreak. Resident 108, who was cognitively intact with a BIMS score of 15 out of 15, expressed a preference for regular plates and utensils instead of the Styrofoam containers and plastic utensils provided. Despite not being affected by COVID-19, the resident was subjected to the same dining restrictions as those in isolation, which was against the facility's policy that allowed for reusable dishes and utensils for residents on isolation. The decision to use Styrofoam and plastic utensils for all residents on the unit was made by the Director of Nursing and the Administrator, based on a policy from Lutheran. This decision was implemented without considering individual resident preferences or the facility's own policy on isolation precautions. Interviews with staff, including a CNA and the Registered Dietician, confirmed that the use of Styrofoam was a blanket policy for the unit, regardless of individual resident COVID-19 status or preferences. The Vice President of Clinical Operations was unaware of the resident's expressed desire for regular dining ware, indicating a communication gap in addressing resident preferences.
Resident Not Involved in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident, identified as R95, was afforded the right to participate in the development and implementation of his person-centered care plan. The facility's policy mandates that residents, along with their families or legal representatives, are encouraged to participate in care plan meetings, which should be scheduled at convenient times. However, R95, who was cognitively intact with a BIMS score of 15, was unaware of his care planning meetings. The last documented care plan meeting for R95 was on January 13, 2022, despite the requirement for such meetings to occur every 90 days. During interviews, the Social Services Director (SSD) confirmed responsibility for the care plan meetings and acknowledged that a review with R95 occurred on July 18, 2024, but it was not a full care plan meeting. Furthermore, the SSD could not provide documentation for this meeting, which is required to be recorded in the electronic medical record (EMR). This lack of documentation and failure to conduct a comprehensive care plan meeting within the stipulated timeframe led to the deficiency, placing R95 at risk of not being informed about the goals and outcomes of his care.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before medications were left at the bedside. Resident 114, who was readmitted with diagnoses of dementia, congestive heart failure, and asthma, was observed with an inhaler and a tube of clotrimazole-betamethasone cream on their bed. The resident had a BIMS score indicating they were cognitively intact, yet there was no assessment conducted to determine if they could safely self-administer these medications. The physician orders did not include instructions for these medications to be kept at the bedside. During observations and interviews, it was confirmed by LPN7 and the Director of Nursing that Resident 114 had not been assessed for self-administration of the medications found at the bedside. The facility's policy stated that residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, which had not been done in this case. This oversight had the potential for the resident to over-medicate or for the medications to be accessed by other residents.
Incomplete SNF-ABN Notices for Two Residents
Penalty
Summary
The facility failed to ensure that the CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was accurate and complete for two residents prior to their discharge from Medicare Part A skilled services. For one resident with Parkinson's disease, the ABN notice indicated that skilled care was no longer required, but the section for selecting options regarding payment responsibility was left blank. This omission meant that the resident or their representative was not fully informed about their options and potential financial liability. Similarly, for another resident with dementia, the ABN notice also failed to have the options section completed, leaving the resident or their representative uninformed about their choices and financial responsibilities. During an interview, the Social Services Director admitted to being unaware of the requirement to document the estimated cost per day and acknowledged that the options box should have been checked. This oversight placed the residents and their representatives at risk of not being fully informed about their Medicare coverage and potential liability for services not covered.
Failure to Develop Comprehensive Care Plans for Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for behavioral symptoms for three residents, leading to unmet care needs. Resident 115, with intact cognition, exhibited disruptive behavior by yelling out continuously, which disturbed other residents. Despite being prescribed medications like Lorazepam and Sertraline, there was no care plan addressing these behavioral symptoms. Interviews with staff revealed that the resident's behavior was linked to a desire for companionship, yet no interventions were documented in the care plan. Resident 120, with severely impaired cognition, was prescribed psychotropic medications for anxiety and restlessness. However, the care plan only addressed potential side effects of these medications and did not include any interventions for the behaviors that warranted the prescriptions. The clinical notes did not document any behavioral symptoms, indicating a lack of comprehensive assessment and planning for the resident's needs. Resident 25, with moderately impaired cognition, was also prescribed multiple medications for anxiety but lacked a care plan addressing the specific behaviors leading to these prescriptions. The resident exhibited various disruptive behaviors, including yelling and hallucinations, which were noted in the medication administration record. Interviews with staff indicated that the responsibility for care planning was unclear, with the Social Service Director and MDS Coordinator providing conflicting information about who was responsible for developing and updating care plans for behavioral symptoms.
Inaccurate Care Plan for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Comprehensive Care Plan for a resident, identified as R40, who was part of a sample of 30 residents reviewed for care plans. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, addressing their physical, psychosocial, and functional needs. However, the care plan for R40 included interventions related to diabetes, despite the resident not having a diagnosis of diabetes. This discrepancy was identified during a review of the resident's Nutrition Care Plan, which was dated several months prior to the survey. R40 was admitted to the facility with diagnoses of Parkinson's disease and dementia and was receiving hospice care. The resident's cognitive impairment was severe, as indicated by a Brief Interview for Mental Status (BIMS) score of zero out of 15. During an interview, the Registered Dietician (RD) responsible for the development of the Comprehensive Nutritional Care Plan confirmed that R40 was not diabetic and expressed uncertainty as to why diabetic interventions were included in the care plan. This inaccuracy in the care plan placed the resident at risk of unmet care needs.
Failure to Elevate Resident's Heels as Ordered
Penalty
Summary
The facility failed to ensure that a resident's heels were elevated as ordered, which was necessary to prevent the recurrence of a deep tissue injury. The resident, identified as R94, had a history of hemiplegia or hemiparesis, anxiety, depression, and was at risk for pressure ulcers. The care plan for R94 included interventions for skin integrity issues and specifically ordered that the resident's heels be floated on a device while in bed. However, during multiple observations, it was noted that R94's feet were not elevated, and no positioning device was in place. Interviews with staff revealed a lack of awareness and adherence to the care plan. LPN6 confirmed that R94's feet were not elevated and acknowledged the resident's past skin issues. CNA3 was unaware of the requirement to elevate R94's feet and confirmed that they were not elevated during observation. LPN5, who was interviewed later, stated that R94's wounds were healed and was unaware of the need for heel elevation. This lack of compliance with the care plan and staff awareness contributed to the deficiency identified in the report.
Failure to Implement Splint/Palm Protector Orders
Penalty
Summary
The facility failed to carry out orders for a splint/palm protector for a resident with limited range of motion (ROM), potentially causing further decrease of ROM and/or pain. The resident, who had severe cognitive impairment and diagnoses including hemiplegia, anxiety, and depression, was observed multiple times without the prescribed splint or palm protector in place. The resident's care plan did not address the contracture or the use of the splint/palm protector, despite orders indicating its necessity for positioning and contracture management. Interviews with staff revealed confusion and inconsistency regarding the application of the splint/palm protector. A Licensed Practical Nurse confirmed the absence of the device, and the Director of Therapy noted a contradiction between continuous and PRN orders. The Occupational Therapist mentioned a system limitation in documenting the palm protector and acknowledged the order's inconsistency. The Director of Nursing was unaware of documentation for the device's application, and the Treatment Administration Record showed no evidence of the splint/palm protector being applied.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to properly store an oxygen tank in a resident's room and in a storage room, creating a potential hazard. In the case of the resident, identified as R100, who was admitted with acute and chronic respiratory failure, COPD, and other viral pneumonia, an oxygen tank was observed free-standing on the floor without being secured in a holder. This observation was made during a survey, and it was noted that the oxygen tank holder was available but not used. A Licensed Practical Nurse (LPN) acknowledged the improper storage and secured the tank in the holder. Additionally, in one of the storage rooms, an oxygen tank was found free-standing on the floor instead of being stored in the designated storage bin. The LPN confirmed that the tank should have been placed in the storage bin. Interviews with the Unit Manager and the Director of Nursing revealed that the facility's policy required oxygen tanks to be stored in racks with chains, sturdy portable carts, or approved stands, and never left free-standing. The facility's failure to adhere to this policy was identified as a deficiency.
Inadequate Nutritional Monitoring and Care
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for three residents, leading to potential health risks. For one resident, R120, the facility did not accurately monitor weight changes or meal intake. Despite being on a regular diet with thin liquids, R120 experienced significant weight loss over a short period. Observations revealed that R120 often did not consume the meals provided, and staff failed to encourage eating or offer alternatives when the resident expressed dissatisfaction with the food. The Registered Dietitian (RD) acknowledged inaccuracies in weight records and incomplete meal documentation, which hindered proper nutritional assessment. Another resident, R115, also faced issues with nutritional management. Despite being on a mechanically altered diet, R115 experienced significant weight fluctuations. The facility did not consistently document meal consumption, and there were instances where R115 did not receive a meal tray. The RD noted discrepancies in weight records and relied on incomplete data for assessments. The lack of accurate and consistent monitoring of R115's nutritional intake and weight contributed to the deficiency. For resident R68, the facility failed to provide consistent and accurate weight monitoring. R68 experienced significant weight loss since admission, but the RD suspected inaccuracies in the initial weight records. The RD requested reweights but noted ongoing issues with weight accuracy throughout the facility. The absence of regular nutrition risk meetings and reliance on morning meetings for reweight requests further contributed to the deficiency. These failures in monitoring and documentation led to inadequate nutritional care for the residents involved.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to monitor the prophylactic use of an antibiotic for a resident, identified as R16, who was part of a sample of 30 residents reviewed for antibiotic stewardship. R16 was admitted with diagnoses including congestive heart failure and dementia and was cognitively intact with a BIMS score of 14 out of 15. The resident had been on a daily antibiotic, Nitrofurantoin, for a personal history of urinary tract infections. However, the comprehensive care plan did not address the prophylactic use of this antibiotic, and there was no documentation of symptom monitoring or rationale for its continued use. Interviews with facility staff revealed that while infection control meetings were held monthly, they did not specifically address the long-term use of prophylactic antibiotics. The Pharmacy Consultant had sent a letter to the physician regarding the antibiotic use, but no further follow-up was conducted. The physician disagreed with discontinuing the antibiotic, citing stability on the current regimen, yet failed to provide documentation or rationale for this decision. This lack of monitoring and documentation placed the resident at risk of unmet care needs related to prolonged antibiotic use.
Failure to Maintain Resident Safety During Incontinent Care
Penalty
Summary
The facility failed to maintain resident safety from harm for one resident. Specifically, while providing incontinent care to a resident, staff walked away, resulting in the resident falling to the floor and suffering multiple injuries, including a hematoma of the scalp, a skin tear and hematoma over the right elbow/forearm, and an acute closed fracture of the tibia and fibula. The incident occurred when two CNAs were providing care, and one turned away to dispose of soiled items, leaving the resident unsupported, leading to the fall. The resident involved had a significant medical history, including bed confinement status, encephalopathy, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and major depressive disorder. The resident was severely cognitively impaired and dependent on staff for all activities of daily living, including personal hygiene and toileting. The resident's care plan indicated a potential for falls and injuries related to imbalance and muscle weakness, with specific interventions requiring two staff members for transfers, toileting, dressing, bathing, and providing care. On the day of the incident, the resident was being turned on her left side for incontinence care by two CNAs. One CNA turned away to dispose of soiled items, and the resident fell to the floor face down. The CNAs and the nurse assessed the resident, who was then transferred to a local hospital. The resident's representative expressed concerns about the incident, stating that the facility staff dropped the resident during care. The facility's Director of Nursing and Administrator confirmed the incident and the resident's injuries.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
