Millennium Post Acute Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in West Columbia, South Carolina.
- Location
- 2416 Sunset Boulevard, West Columbia, South Carolina 29169
- CMS Provider Number
- 425105
- Inspections on file
- 21
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Millennium Post Acute Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain proper laundry disinfection when the laundry boiler was malfunctioning and wash temperatures were only 62 to 65 degrees Fahrenheit, while staff used Oxi-Clean in loads and were unsure of the required hot water temperature. The facility also failed to ensure proper hand hygiene and PPE use during med pass: an LPN touched a resident and administered oral meds and eye drops without appropriate glove changes and hand hygiene, and another LPN administered insulin after handling room surfaces with the same gloves.
PASARR screening was not completed before admission for two residents reviewed. One resident had diagnoses including chronic respiratory failure, DM2, MDD, and anxiety disorder, and another had rheumatoid arthritis, mood disorder, anxiety disorder, schizophrenia, and MDD. The SSD said the facility was redoing incorrectly completed PASARR Level 1s after admission, and the DON stated Level 1 PASARRs are required for entry and Level 2s are needed for certain psychiatric histories.
A resident’s wheelchair was observed with a brown leaf and visible white stains on the back and wheels on repeated checks. The resident had diagnoses including muscle wasting atrophy, unsteadiness on feet, pain in the left hip, stiffness of joint, muscle weakness, and difficulty walking, and was cognitively intact with a BIMS score of 13/15. Staff gave differing accounts of wheelchair cleaning practices, and the DON and DOLLS both observed the wheelchair was visibly dirty.
A facility with over 120 certified beds failed to employ a full-time qualified LMSW after the previous Social Services Director left. Since then, a Social Services Assistant with a CNA background has attempted to fill the role, with some support from a corporate liaison and an RN, but no licensed social worker was on staff. This left all residents potentially affected by the lack of required psychosocial support and services.
Staff failed to secure PHI for two residents by leaving sensitive documents uncovered in a clear mailbox accessible to others and by leaving a computer unattended in a common area with a resident's face sheet visible. Facility leadership confirmed these actions were not in line with HIPAA or facility policy.
A resident with chronic respiratory failure and ventilator dependence did not receive tracheostomy tie changes as required by facility policy, and there was no documentation of these changes for an entire month. Staff interviews confirmed that the order for trach tie changes was not consistently maintained or documented, leading to a lapse in care.
A resident was found with an unattended cup of Guaifenesin (Robitussin) at the bedside, and a loose pill of Sulfamethoxazole and Trimethoprim was discovered without documentation or provider orders. Nursing staff could not account for the medications, and no self-administration assessment or authorization was present. Facility policy requiring provider orders, proper documentation, and secure storage of medications was not followed.
A resident with multiple chronic conditions was placed on a heart-healthy, consistent carbohydrate diet but reported dissatisfaction with repetitive meals and an inability to read the posted menu. Staff interviews confirmed the menu was not legible to the resident, and there was uncertainty about meal portion sizes. Despite efforts to accommodate preferences, the facility failed to ensure the resident received a nourishing, palatable, well-balanced diet that met both nutritional needs and personal preferences.
A resident with significant mobility impairments was found unable to reach the call bell, which had been placed on the opposite side of the bed. The resident experienced severe pain and was unable to request assistance for over 15 minutes. An LPN confirmed the call bell was out of reach, and staff interviews revealed that facility policy requires call bells to be accessible at all times, but this expectation was not met, resulting in a delay in care.
A resident with end-stage renal disease and type 2 diabetes did not receive prescribed medications and nutritional supplements on dialysis days. The LPN confirmed the resident missed doses, and the physician was not notified. The NP acknowledged the orders should have indicated medication administration during dialysis, but they did not. The DON could not provide expectations on ensuring staff followed physician orders, indicating a lack of oversight.
A resident, totally dependent on staff and unable to voice needs, fell from bed due to inadequate supervision by an LPN and a distracted CNA. The resident coughed and slid off the bed, resulting in facial swelling and redness. The facility's root cause analysis failed to accurately identify the events leading to the fall, highlighting a lapse in adherence to the facility's fall management policy.
A resident with significant weight loss did not receive the physician-ordered Mighty Shakes with meals due to a communication failure between the Registered Dietician and the Dietary Manager. Observations and staff interviews confirmed the absence of the supplement on the resident's meal trays, placing the resident at risk for further weight loss.
A resident's clinical records were found to be incomplete and inaccurately documented, as the resident did not receive a prescribed nutritional supplement, Mighty Shakes, with meals despite records indicating otherwise. Observations confirmed the absence of the supplement, and interviews with LPNs revealed reliance on CNAs for verification, leading to documentation inaccuracies. The DON acknowledged the issue with one LPN's practices.
The facility failed to develop a comprehensive care plan for a resident with anoxic brain damage and a guardian, neglecting to address the mother's interference with care and the need to contact her after notifying the guardian. The DON revealed that the mother's language barrier led to a misunderstanding about the resident's catheter, which was resolved without a care plan in place.
Infection Control Failures in Laundry Sanitization and Medication Administration
Penalty
Summary
The facility failed to ensure linen and resident clothing were washed at appropriate temperatures or with proper disinfection in the laundry room. During observation, the industrial washing machine was running at 62 to 65 degrees Fahrenheit, and the laundry assistant confirmed that reading. The assistant stated he was not sure of the proper hot water temperature for laundry and also reported that the laundry room boiler had been a problem. The laundry room was observed with chemical products connected to an automatic dispensing system, including bleach, sour/softener, alkali, and detergent. Further review and interviews showed the boiler supplying hot water to the laundry room had been malfunctioning for about 2.5 weeks and was leaking water from the bottom of the tank. The maintenance assistant reported the riser thermometer gauge read 64 degrees Fahrenheit and the water heater thermometer gauge read 65 degrees Fahrenheit. The maintenance/life safety director stated the boiler had been malfunctioning from time to time, that a new boiler had been ordered, and that when the current boiler worked the temperature was between 140 and 160 degrees Fahrenheit. The laundry attendant stated she had been using 1.5 to 2 cups of Oxi-Clean Versatile Stain Removal in each laundry load since the boiler had been malfunctioning. The infection preventionist stated she had been made aware of the boiler being out of order a few weeks earlier but was not aware it was still out of order and was not aware of the Oxi-Clean product being used. The facility also failed to ensure medications were administered using proper hand hygiene and PPE during medication pass for two residents. One LPN entered a resident's room on Enhanced Barrier Precautions, touched the bed control and the resident's face and head with bare hands while positioning the resident for oral medications, and did not wear gloves for those actions. In another observation, the same LPN administered eye drops and oral medication to a resident on Enhanced Barrier Precautions, removed gloves after the eye drops, but did not perform hand hygiene before giving the oral medication or before putting on a new pair of gloves for a second eye drop. A second LPN applied gloves before entering another resident's room, closed the privacy curtains and room door with gloved hands, and then administered insulin without removing the gloves or performing hand hygiene. The DON stated she could not defend the nurse touching environmental surfaces and giving insulin with the same gloves, and the infection preventionist stated the nurses should remove gloves and perform hand hygiene before entering the room, after touching environmental surfaces, and before administering medication.
PASARR Screening Not Completed Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed prior to admission for 2 of 7 residents reviewed. The facility did not have a policy related to PASARR assessments. Review of one resident’s face sheet showed admission with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder, and the resident’s PASARR Level 1 was completed by the facility after admission. Review of another resident’s face sheet showed admission with diagnoses including rheumatoid arthritis, mood disorder, anxiety disorder, schizophrenia, and major depressive disorder, and that resident’s PASARR Level 1 was also completed by the facility after admission. During interview, the SSD stated she was checking all PASARR Level 1s because they had not been completed correctly, and that the department was having to redo the PASARRs. She stated there had been pushback from hospitals about completing them, so her department had been correcting them by reviewing hospital records and obtaining information from the resident and/or family. The SSD also stated that a licensed social worker or nurse can complete a Level 1, while a Level 2 has to be completed with a physician. The DON stated that Level 1 PASARRs are required for entry into the facility and Level 2s are required if there had been a recent psychiatric stay or diagnosis, and that if the facility did not receive a Level 1 prior to entry, the facility social worker could complete it or try to obtain one from the hospital or community.
Dirty Wheelchair Observed for Resident 1
Penalty
Summary
The facility failed to ensure Resident 1’s adaptive equipment was clean. Resident 1 was admitted with diagnoses including muscle wasting atrophy, unsteadiness on feet, pain in the left hip, stiffness of joint, muscle weakness, and difficulty walking. The quarterly MDS showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact, and also documented that the resident used a wheelchair. During observations, Resident 1’s wheelchair leaf was noted to be brown, with white stains visible on the back of the wheelchair and on the wheels. The same condition was observed again the following day. Staff interviews revealed differing practices for wheelchair cleaning, including housekeeping cleaning wheelchairs at least monthly, daily sanitizing if the chair was empty, and cleaning as needed when soiled. The Director of Housekeeping and Laundry Services later acknowledged visible debris on the wheelchair and stated the last cleaning had occurred several days earlier. The DON also observed that the wheelchair was visibly dirty.
Failure to Employ Full-Time LMSW in Facility with Over 120 Beds
Penalty
Summary
The facility failed to employ a full-time qualified Licensed Medical Social Worker (LMSW) as required for facilities with more than 120 certified beds. Record review showed that the facility was certified for 132 beds, but there was no LMSW employed at the time of the survey. The Social Services Director, who was a social worker, left the facility in mid-August, and since then, the facility has been without a licensed social worker. The Social Services Assistant (SSA), whose background is as a Certified Nursing Assistant (CNA), has been attempting to fill the role in the interim, with some support from a corporate liaison whose official title and role were unclear to the SSA. Interviews with facility leadership, including the Administrator, DON, and ADON, confirmed that the responsibilities of the social worker included scheduling care plans, handling grievances, assisting with discharge planning, and coordinating discharge and home health services. It was further confirmed that the facility had no LMSW on staff at the time of the survey, and the resource currently supporting the SSA was an RN, not an LMSW. All 130/130 certified beds were potentially affected by the absence of a full-time LMSW to provide necessary psychosocial support and services.
Failure to Secure Resident PHI in Public Areas
Penalty
Summary
The facility failed to maintain the confidentiality and security of resident Protected Health Information (PHI) for two residents. Specifically, a resident's code status document containing PHI was observed uncovered and unsecured in a clear wall-mounted mailbox located in a hallway accessible to staff, residents, and visitors. Additionally, documents such as advance directives and a signed Do Not Resuscitate order were left exposed in the same mailbox, making sensitive information easily accessible and not in compliance with facility policy. Further, a staff member left a computer on wheels (COW) unattended in a common area with the screen displaying a resident face sheet, including the resident's name, photograph, and medical details. The Assistant Director of Nursing was observed later securing the computer and closing the resident's chart. Interviews with facility staff and leadership confirmed that these actions were not in accordance with facility policy or HIPAA regulations, and that PHI should not have been left visible or unattended in these areas.
Failure to Ensure Proper Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to ensure proper tracheostomy care for a resident with chronic respiratory failure, ventilator dependence, functional quadriplegia, and a persistent vegetative state. According to facility policy, tracheostomy ties should be changed every seven days, after showers, or when visibly soiled. The resident's Respiratory Administration Record included an order to change the trach ties weekly and as needed, but the August Medication Administration Record did not reflect this order. Observations and interviews revealed that there was no documentation of tracheostomy tie changes for the month of August, and staff confirmed that the order for changing the ties had lapsed when the resident was in and out of the hospital. Interviews with staff, including an LPN, a respiratory therapist, and the Director of Respiratory, indicated that while the responsibility for changing the tracheostomy ties was understood, the actual documentation and consistent performance of this task were lacking. The Director of Respiratory acknowledged the absence of documentation and noted that the issue was only discovered upon review. The DON stated that staff are checked off on this skill during annual training, but this did not ensure ongoing compliance with the required frequency of tracheostomy tie changes or proper documentation.
Failure to Secure and Document Medication Administration
Penalty
Summary
Facility staff failed to ensure that medications were properly stored and administered according to policy and professional standards. During an observation, a medication cup containing a red liquid identified as Guaifenesin (Robitussin) was found unattended on a resident's bedside table. The resident reported that the cough medicine was given by a night shift nurse two nights prior. There was no documentation of a self-administration assessment or a provider order authorizing the resident to self-administer medication. Additionally, a loose white pill identified as Sulfamethoxazole and Trimethoprim was found, with no staff able to account for its origin or intended recipient, and no corresponding order in the resident's records for either medication in the preceding three days. Review of the resident's electronic health record confirmed the absence of any provider order or documentation for the administration of cough medication or Sulfamethoxazole and Trimethoprim. Interviews with nursing staff and facility leadership revealed that the nurse who administered the cough medication did not obtain a provider order and failed to document the administration or the need for the medication. Facility policy requires that medications be administered only with a valid provider order, be documented in the Medication Administration Record, and not be left at the resident's bedside. These protocols were not followed in this instance, resulting in the deficiency.
Failure to Ensure Resident Receives Palatable, Well-Balanced Diet Respecting Preferences
Penalty
Summary
The facility failed to ensure the nutritional well-being of a resident while also respecting the individual's right to make choices about their diet. The resident, who had diagnoses including chronic respiratory failure, tracheostomy status, COPD, and hypertensive heart disease, was placed on a heart-healthy, consistent carbohydrate diet with specific restrictions. Despite having an intact cognitive status, the resident reported dissatisfaction with the repetitive nature of the meals, specifically mentioning frequent servings of chicken and occasional meals without meat. The resident also expressed a lack of understanding about the heart-healthy diet and reported not being able to read the posted menu in their room. Interviews with staff revealed that dietary preferences were supposed to be accommodated through a preference slip and that an alternate menu was posted in the resident's room. However, both the surveyor and the resident confirmed that the menu was not legible to the resident. The Dietary Assistant Supervisor acknowledged the issue and stated that while efforts were made to accommodate preferences and provide alternatives, changes to the diet required permission, and there was uncertainty about portion sizes for certain meals. The staff also indicated that the resident could request changes through CNAs or nurses, but the resident had not requested more food. Further, the administrator noted challenges with the resident and their representative bringing in outside food and not adhering to the prescribed diet, despite education efforts. The Registered Dietitian monitored the resident's intake and menu compliance, but the resident continued to express dissatisfaction with the food provided and the lack of variety. These actions and inactions led to a failure to provide a nourishing, palatable, well-balanced diet that met the resident's nutritional and personal preferences, as required by regulation.
Call Bell Inaccessibility Leads to Delay in Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for self-care and mobility due to muscle weakness and a history of cerebral infarction, was found in bed with the call bell positioned out of reach on the opposite side of the bed. The resident, who had impairment in both lower extremities, was unable to access the call bell and reported being in significant pain, rating it as 8 out of 10. The resident stated she had been trying to get staff attention for over 15 minutes to request pain medication but was unable to do so due to the call bell's placement. During the observation, a Licensed Practical Nurse confirmed that the call bell was not within the resident's reach and acknowledged that facility policy requires call bells to be accessible to all residents at all times. The facility's policy and staff interviews indicated that staff are expected to ensure call bells are within reach before leaving a resident's room and to conduct regular rounding. In this instance, these expectations were not met, resulting in a delay in care for the resident.
Failure to Administer Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure that all medications were appropriately administered on dialysis days for a resident with end-stage renal disease and type 2 diabetes. The resident, who had significant cognitive impairment, was scheduled to attend hemodialysis on Tuesdays, Thursdays, and Saturdays. However, the Medication Administration Record revealed that the resident's medications, including Midodrine and Sevelamer, as well as a nutritional supplement, were not regularly administered on these days. This oversight was confirmed during an interview with an LPN, who admitted that the resident missed the second dose of blood pressure medication and the nutritional supplement on dialysis days, and the physician was not notified of these missed medications. Further interviews revealed a lack of clarity and communication regarding medication administration during dialysis times. The Nurse Practitioner acknowledged that while it was understood that dialysis residents did not receive medications during dialysis, the orders should have reflected this, which they did not. The Director of Nursing was unable to provide information or expectations on ensuring staff followed physician orders for medication administration, indicating a gap in oversight and communication within the facility. This deficiency highlights a failure in the facility's processes to ensure residents receive their prescribed treatments consistently.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in a fall from bed. The resident, who was totally dependent on staff for activities of daily living and unable to voice her needs due to a tracheostomy, was being cared for by an LPN and a CNA when the incident occurred. The resident coughed and slid off the bed, landing on her right side, which led to swelling and redness on her face. The resident was sent to the emergency room for evaluation, where it was determined that no head or neck injury was sustained. The root cause analysis conducted by the facility was inadequate, as it failed to accurately identify the events leading to the fall. The LPN reported turning the resident towards the CNA, who did not have her hands on the resident at the time of the fall. The CNA admitted to being distracted and unable to prevent the fall. The facility's policy on fall management emphasizes the importance of providing an environment free of accident hazards and adequate supervision, which was not adhered to in this case.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident identified as having significant weight loss. The resident, who was moderately cognitively impaired, was ordered by a medical provider to receive Mighty Shakes, a nutritional supplement, with meals. However, observations and interviews revealed that the resident did not receive the supplement as ordered. The resident's meal trays did not include the Mighty Shake, and the meal tickets did not list it, indicating a failure in communication and implementation of the dietary order. Interviews with staff, including CNAs, LPNs, and the Dietary Manager, confirmed that the order for the Mighty Shakes was not communicated to the kitchen. The Registered Dietician stated that a report was supposed to be sent to the Dietary Manager, but this communication was missed, resulting in the resident not receiving the necessary nutritional supplement. This oversight placed the resident at risk for further weight loss, as the dietary intervention was not implemented as per the physician's order.
Inaccurate Documentation of Nutritional Supplement Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for one resident, identified as R75. The deficiency was identified during a review of R75's medical records, which revealed that the resident was ordered a nutritional supplement, Mighty Shakes, with meals. However, observations on two separate occasions showed that the resident did not receive the Mighty Shake with their meals, despite documentation in the Medication Administration Record (MAR) indicating that the supplement was provided. Interviews with staff, including LPN1 and LPN8, revealed inconsistencies in the process of verifying and documenting the consumption of the Mighty Shake. LPN1 admitted to relying on CNAs to confirm whether the resident consumed the supplement, rather than verifying it personally. The Director of Nursing acknowledged the issue, attributing it to LPN1's documentation practices, but denied any fraudulent documentation by all nurses. This failure to ensure accurate documentation had the potential to impact the resident's care.
Failure to Develop Comprehensive Care Plan for Resident with Guardian and Family Interference
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with anoxic brain damage and persistent vegetative state. The resident's electronic health record indicated that the guardian should be notified before the mother in case of any changes. However, the care plan did not include instructions regarding the mother's interference with care or the need to contact her after notifying the guardian. The Social Services Director and the MDS Nurse both confirmed that they do not typically care plan for guardianship or family interference issues. The Director of Nursing revealed that the resident's mother, who has a language barrier, was trying to communicate concerns about the resident's catheter size. This led to a misunderstanding where staff thought she was interfering with the catheter. The issue was resolved by using a language line and adjusting the catheter size, but this situation highlighted the lack of a care plan addressing who to contact and when. Additionally, the mother's contact information was not listed in the resident's paperwork.
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.
