Nhc Healthcare - Charleston
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, South Carolina.
- Location
- 2230 Ashley Crossing Drive, Charleston, South Carolina 29414
- CMS Provider Number
- 425381
- Inspections on file
- 19
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Nhc Healthcare - Charleston during CMS and state inspections, most recent first.
A resident with anxiety, depression, and no diabetes diagnosis was given insulin glargine on two occasions even though the order had no documented indication for use. The MAR showed the insulin was administered by nursing staff, and the resident reported she was not diabetic, felt sleepy after the second dose, and became more anxious afterward. Interviews and record review showed the insulin was entered in error and was not part of the resident’s treatment plan.
Improper storage of expired medications and biologicals was found in 2 medication rooms. Surveyors observed expired Augmentin bottles in active storage, an opened Aplisol vial that was not dated when opened despite manufacturer instructions to discard after 30 days, and expired fecal occult blood test kits on a shelf near the refrigerator. RN and LPN staff verified the expired items, and the DON stated the items should not have been left in active storage and that Aplisol should have been dated when opened.
A resident’s dignity was not protected when a CNA left him seated at a table in a common area with an uncovered urinary catheter bag hanging beneath his wheelchair and fully visible to staff, other residents, and a visitor. An RN confirmed the bag was not covered, and the DON stated urinary bags should be covered to protect resident dignity.
A resident who was cognitively intact and not diagnosed with diabetes was inadvertently given insulin glargine on 2 days after an erroneous order was entered. The MAR showed the insulin was administered, later NP documentation stated it was not a prescribed med for the resident, and the resident was upset that she had been given insulin. The MD said he was not notified until the NP contacted him several days later and stated he would have expected to be notified sooner.
The facility failed to ensure 4 of 4 missing OBRA MDS assessments were corrected, completed, and transmitted on time. The MDS Coordinator coded the assessments as completed, but they were not submitted to the state agency and remained only as completed in the computer system. The MDS Coordinator and AR Nurse confirmed the assessments had not been transmitted timely.
A resident was admitted to a hospital with severe bruising, multiple infected wounds, and a foul odor, later expiring in the hospital. The resident's medical history included conditions like depression and enterocolitis. Facility records showed healed skin tears, but the resident was found with numerous wounds and a staph infection. Interviews with staff revealed a lack of awareness and reporting of the resident's condition, contributing to neglect.
Unnecessary Insulin Administered Without a Valid Indication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it administered insulin glargine to a resident who did not have a diagnosis or history of diabetes or blood glucose complications. The resident was admitted with diagnoses including bacterial pneumonia, hypertension, insomnia, major depressive disorder, and generalized anxiety disorder, and her MDS did not identify diabetes or any insulin use. Her care plan addressed anxiety and depression, but there were no care plan problems or interventions related to diabetes or insulin therapy. The resident’s medication record showed an order for Lantus Solostar U-100 Insulin, 10 units subcutaneously daily, entered with no diagnosis or indication for use. A second insulin glargine order also appeared in the record without a diagnosis or indication. The MAR showed that the resident received insulin on two separate days, while additional scheduled doses were refused. The psychiatric NP’s evaluation and follow-up notes reflected treatment for anxiety and depression, and the psychiatric provider reviewed the resident’s medications without any indication that insulin was part of her treatment plan. During interviews, the resident stated she was not diabetic and reported that after the second insulin injection she felt sleepy and believed the medication was an error. She also stated that her anxiety worsened after the incident and that she became concerned about receiving medications from nursing staff. The resident and her representative reported that the nurse did not check her blood sugar before giving the insulin. Facility staff acknowledged that the insulin order had been entered incorrectly and that the resident had received the medication despite lacking a diabetic diagnosis.
Improper Storage of Expired Medications and Biologicals
Penalty
Summary
Drugs and biologicals were not properly stored in 2 of 2 medication rooms. The facility policy titled MEDICATION STORAGE IN THE FACILITY, revised on 2/25/2025, states that medications and biologicals are to be stored safely, securely, and properly, following manufacturer or supplier recommendations, and that all expired medications are to be removed from active supply and destroyed in the facility. During observation on 03/31/2026 at approximately 10:55 AM in the 200 Hall Medication Room refrigerator, surveyors found 2 bottles of Augmentin 400 mg/5 ml in active storage that were labeled by pharmacy as Do No Use After 3/28/26 and Do Not Use After 3/27/26. The same refrigerator also contained 1 opened vial of Purified Protein Derivative/Aplisol 5 TU/1 ml that was approximately 20% full and had not been dated when opened, despite manufacturer labeling stating that once entered it must be discarded after 30 days. During interview, RN1 verified that the Aplisol vial had not been dated when opened and that the Augmentin bottles were expired. Later that day, during observation of the Hall 100 Medication Room, surveyors found 8 Fecal Occult Blood Tests Lab Kits with an expiration date of 12/03/2025 on a shelf near the refrigerator. LPN1 verified that the fecal occult blood tests had expired. During interview on 04/01/2026, the DON reviewed the medication storage findings and stated that those items should not have been left in active storage and that Aplisol should have been dated when opened.
Uncovered Urinary Catheter Bag Left Visible in Common Area
Penalty
Summary
Resident R9’s dignity was not protected when his urinary catheter bag was left uncovered and fully visible while he was seated in his wheelchair in a common area near the nursing station. During the initial tour, a CNA rolled R9 to a table in the common area and walked away, leaving him there with the catheter bag hanging beneath his wheelchair. The bag was observed approximately 3/4 full and remained uncovered and visible during a later observation while multiple staff members, other residents, and a visitor were in the immediate area. RN2 observed R9 and confirmed that the urinary bag was not covered and stated it should be covered. The facility policy stated that privacy, dignity, and confidentiality should be respected, and the DON stated that urinary bags should be covered to protect resident dignity.
Delayed physician notification after inadvertent insulin administration
Penalty
Summary
The facility failed to ensure that Resident 24’s Medical Doctor/Medical Director was informed in a timely manner after an inadvertent administration of insulin. The facility policy required the charge nurse to notify the physician or physician extender immediately when a patient’s condition changed, and to contact the Medical Director if the attending or alternate physician was unavailable. Resident 24 was admitted with diagnoses including bacterial pneumonia, primary hypertension, primary insomnia, major depressive disorder, and generalized anxiety disorder, and her admission MDS showed a BIMS score of 13, indicating she was cognitively intact. The MDS also showed she was not diagnosed with diabetes mellitus and did not receive injections, including insulin, during the assessment period. Despite this, the MAR showed an order for insulin glargine 10 units subcutaneously daily beginning 03/25/26, and the medication was administered on 03/26/26 and 03/27/26. A nurse practitioner note later stated that insulin glargine was not a prescribed medication for this patient and that the order should be disregarded. Another NP note documented that the resident was upset that she had been inadvertently given insulin and that her family was aware and the issue had already been addressed by the DON. During interview, the Medical Director stated he was not notified until 04/01/26 by the resident’s NP, even though the NP had been aware of the incident since 03/30/26, and he stated he would have expected to be notified sooner.
Missing OBRA Assessments Not Transmitted
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for 4 of 4 residents listed on the Missing OBRA Assessment Report were corrected, completed, and transmitted in a timely manner. Review of the CMS LTC Facility Resident Assessment Instrument 3.0 showed that required MDS 3.0 sections, including the CAA Summary and all tracking or correction information, must be transmitted as part of the assessment record. The State Agency’s Missing OBRA Assessment report identified 4 residents with missing assessments, and review of those assessments showed they were coded as completed by the MDS Coordinator but were not submitted after completion. During interview, the MDS Coordinator and the Assistant Regional Nurse confirmed that the missing OBRA assessments had been completed but were not sent to the state agency timely and were only showing in the computer system as completed, not transmitted.
Neglect Leads to Severe Health Deterioration in Resident
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in severe health deterioration. The resident was admitted to a local hospital with severe bruising, multiple infected wounds, and a foul odor, and later expired in the hospital. The resident's medical history included conditions such as a history of falling, macular degeneration, depression, and enterocolitis due to Clostridium difficile. Upon admission to the facility, the resident was cognitively intact and did not have any unhealed pressure ulcers or injuries. The facility's records indicated that the resident had a skin tear on the right lower forearm, which was documented as healed. However, subsequent observations revealed skin tears on both arms and legs, with no open lesions or wound infections noted. Despite these observations, the resident was later found at the hospital with abnormal bruising, multiple wounds with greenish pus, and a foul smell. The hospital records indicated the presence of numerous skin tears, fractures, and a staph infection, leading to sepsis. Interviews with facility staff, including the Wound Care Nurse, Registered Nurse, and Director of Nursing, revealed a lack of awareness and reporting of the resident's deteriorating condition. The staff consistently reported that the resident only had minor skin tears and bruising, with no severe wounds or pressure sores. This lack of proper assessment and reporting contributed to the neglect and subsequent severe health issues experienced by the resident.
Removal Plan
- All patients in certified beds had a skin audit performed for any new, known or worsened skin breakdown to include skin tears and pressure injuries. Any newly identified or worsened area were immediately reported to the patient's provider and responsible party. Skin audits completed by nursing management team with no new areas of concerns identified.
- Education was provided to all licensed nurses on how to perform a skin assessment, proper treatments based on physician orders, and proper documentation. All in-house nursing partners educated by Assistant DON and remaining nurses education will be completed by ADON and designee.
- Education to all certified nurse aides on how to observe skin while performing ADL care as well as provide skin care and pressure relief. All in-house nursing partners educated by Assistant DON and remaining CNA education will be completed by ADON and designee.
- For ongoing monitoring, the DON or designee will review all patients with skin treatments to review for changes in wound appearances. Any new admission will be included in this monitoring. Changes in skin condition will be reported to the patient's provider. Daily x2 weeks, twice per week for 2 weeks, Weekly for 1 month and Monthly until deemed no concerns by the QA committee.
- A QAPI meeting was held with the Administrator, DON, Assistant DON, Nurse Manager, Assistant Regional Nurse, Social Worker Director, HIM Director, and Dietary Manager. The alleged events were discussed in detail and processes that need to be completed and implemented to assure resident safety from situations of neglect are followed up on appropriately. The processes will be communicated to all partners through the in-service listed above. Compliance of the above was achieved.
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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