White Oak At North Grove Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Spartanburg, South Carolina.
- Location
- 290 N Grove Medical Park Drive, Spartanburg, South Carolina 29303
- CMS Provider Number
- 425408
- Inspections on file
- 20
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at White Oak At North Grove Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of falls, and documented need for a gait belt and walker during transfers was ambulated from the bathroom by a CNA without a gait belt in place. The CNA reported holding the resident’s pants while walking, during which the resident’s feet became twisted and she fell in her room. Facility documentation showed the resident had been assessed as requiring a gait belt, but gait belt use was not included in physician orders or the care plan and was instead communicated via door name tags. The resident sustained a left hip fracture requiring surgical repair and was later readmitted for rehab and strengthening.
The facility failed to follow its food storage and labeling policy, leading to deficiencies in two kitchens. Surveyors found opened and undated food items, such as minced garlic and caramel sauce, and expired items like hot dog buns and cranberry juice. The Certified Dietary Manager stated that expiration dates should be checked upon delivery, but this procedure was not followed.
The facility failed to implement an effective infection prevention and control program. During dining services, a homemaker used bare hands to serve baked potatoes, violating hand hygiene policies. In laundry services, a laundry attendant contaminated a clean linen cart with soiled PPE and improperly removed her gown, leading to self-contamination. The Dietary Manager and Laundry Director acknowledged these actions were incorrect, and the Corporate Nurse Consultant noted existing infection control issues.
The facility failed to involve two cognitively intact residents in their care plan meetings, as required by policy. Despite being invited, the residents did not participate, and there were no signatures on the RAI Process Review Sheets to indicate their involvement. The Social Services Director and Director of Nursing confirmed the protocol for inviting residents, but the meetings were canceled if residents did not attend, with no follow-up unless requested.
A resident admitted for a Medicare Part A stay opted to remain in the facility after services ended. The facility issued the incorrect financial liability notice, CMS-R-131 for Part B services, instead of the required CMS Form-10055 for Part A services. The Business Office Assistant confirmed the error.
The facility failed to provide two residents or their representatives with the Bed Hold Policy in a timely manner during hospitalization. The policy lacked the bed hold amount, and there was no documentation confirming receipt by the residents or their representatives. The facility's process involved sending the policy with the resident to the hospital and later mailing it to the representative, which did not ensure timely notification.
The facility failed to adhere to its policy of labeling dressings with the date and initials for two residents. One resident had a foam dressing on her foot without proper labeling, despite being cognitively intact and having specific physician orders. Another resident's tube feed dressing was also unlabeled, contrary to the facility's policy. An LPN admitted to not labeling the dressing, and the DON confirmed that labeling was expected.
A resident's medications were left unattended at the bedside, contrary to safe storage protocols. The resident, who was cognitively intact, had medications prescribed for daily application. An LPN admitted to leaving the creams on the bed, intending to return but got busy. The DON confirmed that medications should not be left at the bedside.
Failure to Use Required Gait Belt During Ambulation Resulting in Hip Fracture
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards and received adequate supervision during ambulation, resulting in a fall and left hip fracture. The facility’s Fall Management Program policy included staff education and interventions to prevent unsafe transfers and ambulation. The resident had severe cognitive impairment, as evidenced by a BIMS score of 3/15, and used a walker and wheelchair. A Safe Resident Handling Data Collection form documented that a gait belt and walker were required for transfers with staff and that the resident continued to require use of a gait belt. The resident’s care plan included assistance with transfers and ambulation and provision of adaptive equipment, but there was no physician order for a gait belt, and gait belt use was not listed on the care plan. Instead, the Administrator stated that transfer methods, including gait belt use, were communicated via name tags on residents’ doors and that the resident had a history of tripping over her own feet and falling. On the day of the incident, the resident was being assisted by a CNA from the bathroom when the resident’s feet became twisted and she fell to the floor. The CNA reported she was holding the resident’s pants while walking her from the bathroom and acknowledged that the fall was her fault. Documentation indicated the resident fell in her room while being transferred/ambulated from the bathroom with the CNA present, wearing shoes at the time. The Administrator confirmed that the resident had been assessed for gait belt use and that the resident did not have a gait belt on when she fell. The Administrator stated that, in situations where a resident is already in motion without proper equipment, staff should hold the resident and call for help rather than continue ambulation. The resident sustained a subcapital femoral neck fracture of the left hip, required surgical repair at a hospital, and was later readmitted to the facility for rehabilitation and strengthening, with documentation noting she had been confined to a wheelchair prior to the fall and was unlikely to progress beyond her previous level of activity.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to its policy on food storage and labeling, resulting in deficiencies in two of the six kitchens reviewed. During an initial tour, surveyors observed several food items that were opened and undated, including a jar of minced garlic, a 12-pack of hamburger buns, and a bottle of caramel sauce. Additionally, expired items were found, such as six bags of hot dog buns and 13 cups of cranberry juice cocktail. In the emergency food supply, cans of sausage gravy were also noted to be expired. An interview with the Certified Dietary Manager revealed that the facility's procedure is to check expiration dates upon delivery and return items close to expiration, which was not followed in these instances.
Infection Control Deficiencies in Dining and Laundry Services
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by two specific incidents. During dining services, a homemaker was observed using bare hands to grab and serve baked potatoes to residents, which is against the facility's policy and procedure. The Dietary Manager confirmed that this was not the correct practice and acknowledged the need for correction. This action directly contravenes the facility's policy on infection prevention, which emphasizes proper hand hygiene as a critical measure to reduce infection risk. In a separate incident during laundry services, a laundry attendant was seen contaminating a clean linen cart while wearing soiled personal protective equipment (PPE). The attendant also improperly removed her PPE, dragging the soiled side across her back and contaminating herself. The Laundry Director confirmed that the attendant's actions were incorrect and attributed them to nervousness, indicating a need for further education. The Corporate Nurse Consultant acknowledged existing issues with infection control within the facility, suggesting room for improvement.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to allow two residents, R4 and R69, to participate in their care plan meetings and be fully informed about their care and treatment. The facility's policy requires that residents or their representatives participate in the development of their care plans, and that they sign the Resident Assessment Instrument (RAI) Process Review Sheet to indicate their participation. However, for both residents, there were no signatures from them or their representatives on the RAI Process Review Sheets, indicating a lack of participation in the care plan meetings. Resident R4, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, stated that she does not participate in care plan meetings. The facility's Social Services Director (SSD) mentioned that residents are invited to attend care plan meetings through card invitations and verbal invitations, and that if a resident or family member is not present, the meeting does not occur. The Administrator confirmed that the RAI sheets are individualized and should indicate if a resident attended or declined the care plan meeting. Resident R69, also cognitively intact with a BIMS score of 14 out of 15, expressed dissatisfaction with not being informed about care plan meetings. The SSD explained that if a resident declines to attend a care plan meeting, it is noted, and the meeting is canceled without follow-up unless requested by the resident. The Director of Nursing (DON) stated that the social worker is responsible for arranging care plan meetings and ensuring resident invitations, but there were no known care plan issues. The MDS nurse, who completes the care plan review form, was unavailable for comment.
Incorrect Financial Liability Notice Issued
Penalty
Summary
The facility failed to provide the correct form for notice of financial liability to a resident who was admitted for a Medicare Part A stay for therapy services. After the Medicare Part A services ended, the resident chose to remain in the facility. However, instead of issuing the required CMS Form-10055, which is the Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN) for Medicare Part A services, the facility issued CMS-R-131, which is intended for Part B services. The facility's procedure for issuing the SNF-ABN states that providers must give a notice of financial liability when a Medicare beneficiary is receiving a service that the provider believes is not medically necessary or is custodial care. This notice allows the beneficiary to make an informed decision about receiving the service with the understanding that Medicare will likely not cover the cost, making them fully financially liable. The Business Office Assistant confirmed during an interview that the incorrect form was provided to the resident.
Failure to Provide Timely Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #62 and Resident #46, or their personal representatives, received the Bed Hold Policy in a timely manner during their hospitalization. The Bed Hold Policy is supposed to specify the duration of the bed hold and the bed hold amount, but it was found that the policy did not include the bed hold amount. Resident #46 was admitted to the facility with diagnoses including mild cognitive impairment, anxiety disorder, depression, hypotension, and mood disturbance, and had a hospital stay starting on May 7, 2024. There was no documentation to confirm that Resident #46 or her responsible party received a copy of the bed hold policy in a timely manner. Similarly, Resident #62, who was admitted with diagnoses including delirium, mild cognitive impairment, legal blindness, and a cerebrovascular accident, had a hospital stay beginning on April 28, 2024. The medical record for Resident #62 also lacked documentation to ensure that she or her responsible party received a copy of the bed hold policy. During an interview, the facility Administrator stated that a copy of the bed hold policy is sent in a packet to the hospital with the resident at the time of discharge and is later mailed to the personal representative. However, this process did not ensure timely receipt of the policy by the residents or their representatives.
Failure to Label Dressings as per Policy
Penalty
Summary
The facility failed to provide necessary care and services consistent with professional standards of practice for two residents, specifically in the area of dressing changes. Resident 10 was observed on multiple occasions with a foam dressing on her left lateral foot that lacked appropriate labeling, such as the date and initials, as required by the facility's policy. This was noted during observations on three separate days. Resident 10's medical records indicated she was cognitively intact, with a BIMS score of 15 out of 15, and had specific physician orders for dressing changes every three days and as needed. Similarly, Resident 26 was observed with a tube feed dressing that was not labeled with the date and initials, as per the facility's policy. Observations were made on three different days, and the resident's physician orders required the dressing to be changed shiftly and as needed to prevent skin breakdown. During an interview, an LPN admitted to not labeling the dressing, despite acknowledging that it was expected and part of the facility's policy. The Director of Nursing confirmed that it was his expectation for nurses to label and date dressings.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications, as observed in the case of a resident whose medications were left unattended at the bedside. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had been admitted with multiple diagnoses including muscle weakness, ataxic gait, atrial fibrillation, and other conditions. During an observation, two medication cups containing a white cream were found on the resident's bed, along with a pair of non-latex gloves. These medications were identified as Triamcinolone 0.1% cream and Clotrimazole 1% topical cream, prescribed for daily application. The incident was acknowledged by an LPN who admitted to leaving the creams on the resident's bed, intending to return but becoming busy with other tasks. The Director of Nursing confirmed that the expectation for nursing staff is not to leave medications at the bedside. This oversight in medication management highlights a lapse in adherence to protocols for the safe storage and administration of medications within the facility.
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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