Oak Hollow Of Sumter Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sumter, South Carolina.
- Location
- 1761 Pinewood Road, Sumter, South Carolina 29154
- CMS Provider Number
- 425310
- Inspections on file
- 21
- Latest survey
- April 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oak Hollow Of Sumter Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to use the correct test strips to monitor sanitation concentrations in the kitchen, resulting in inaccurate records of chlorine levels for both the dishwashing machine and the three-compartment sink. Observations also revealed a trash bin without a lid and dust and debris on top of the dishwashing machine, with the Certified Dietary Manager confirming these sanitation lapses.
The facility did not maintain an effective infection prevention and control program, as evidenced by staff failing to perform hand hygiene, missing signage for Enhanced Barrier Precautions, empty hand sanitizer dispensers, and improper use of PPE. A resident with a suprapubic catheter did not have required precaution signage, and staff were not consistently educated on infection control protocols. Plumbing issues led to shared bathrooms, further impacting infection control efforts.
A resident with a physician's order for TED hose was not provided with the prescribed compression stockings, resulting in red, swollen legs, while another resident with incontinence and mobility issues experienced significant delays in receiving incontinent care. Staff were unaware of care orders due to reliance on verbal handoff and did not follow care plans or the facility's No Pass Zone policy, leading to unmet care needs.
The facility did not have a full-time certified dietary manager or food service manager overseeing the food and nutrition service, as required. Staff reported working without supervision, and the CDM confirmed he was responsible for multiple buildings and had not been present to train or manage the dietary staff. The administrator was unable to confirm the CDM's schedule, and the job description indicated the need for full-time, on-site management, which was not being met.
The facility did not develop or implement a QAPI action plan to address environmental hazards, including damaged fall mats, nail holes in walls, and non-functioning toilets. A resident reported ongoing bathroom access issues, and leadership confirmed awareness of these problems without initiating a Performance Improvement Plan.
A resident using an alternating pressure mattress experienced discomfort and had to relocate to the lobby due to a malfunctioning mattress. The facility lacked a policy for maintaining patient care electrical equipment and did not have documentation of inspection or maintenance for the mattress. The Maintenance Director was unaware of the requirement for electrical testing, leading to the deficiency.
Surveyors identified multiple environmental deficiencies, including cracked drywall, peeling paint, damaged furniture, and black residue in resident rooms and bathrooms. Staff and residents reported ongoing plumbing issues that required shared bathroom use, and a resident described long-standing poor wall conditions with incomplete painting. A corporate executive confirmed that unresolved maintenance concerns persisted after the facility owner left the property.
A resident with a history of aggression physically abused two other residents in the facility. Despite having a care plan in place, the facility failed to prevent the assaults, resulting in one resident sustaining a black eye and experiencing pain. The incidents highlight the facility's inability to manage the aggressive behavior of the resident effectively.
A resident with a history of traumatic brain injury and hemiplegia experienced two falls from a mechanical lift due to broken straps. The first fall resulted in a concussion, and although some staff received re-education, not all involved were retrained. The second fall led to a bruise and skin tear, with no documented investigation conducted. The facility failed to adhere to its policies requiring thorough investigations and proper staff training.
A resident with severe cognitive impairment and multiple diagnoses developed several pressure ulcers due to the facility's failure to follow wound care and repositioning protocols. Despite physician orders and family wishes for comprehensive care, treatments were inconsistently administered, and the resident was not regularly turned, leading to multiple untreated wounds.
A resident with severe cognitive impairment successfully eloped from the facility despite having a care plan indicating a risk for elopement. The resident was found outside the facility, and staff interviews revealed that the resident frequently exhibited exit-seeking behavior. The facility's failure to provide adequate supervision and timely response to the alarm resulted in Immediate Jeopardy and substandard quality of care.
The facility failed to ensure that four CNAs received the minimum 12 hours of annual training as required. The new Administrator was unable to provide documentation supporting the completion of the required training for the CNAs.
The facility failed to complete weekly body audits on all residents and did not ensure weekly treatment audits were completed as per the plan of correction. No documentation was found to confirm that these audits were reviewed by the QAPI Committee. Interviews with the Administrator, Administrator in Training, and DON confirmed these deficiencies.
Failure to Maintain Proper Kitchen Sanitation and Monitoring
Penalty
Summary
Facility staff failed to follow proper sanitation protocols in the kitchen, as evidenced by the use of incorrect test strips to check the sanitation concentrations for both the dishwashing machine and the three-compartment sink. During observations, the test strips used by dietary staff consistently read zero, indicating that the sanitation levels were not being properly monitored. Additionally, a trash bin without a lid was found in front of the refrigerator doors, and dust and debris were observed on top of the dishwashing machine, further indicating lapses in maintaining a clean and sanitary environment. The Certified Dietary Manager confirmed that the wrong test strips were used, which resulted in inaccurate readings for chlorine concentration. The daily dish machine log showed that staff had been recording appropriate chlorine levels, but these readings were not accurate due to the use of incorrect test strips. The CDM also acknowledged the need for cleaning in the kitchen, specifically noting the unclean area on top of the dishwashing machine and the uncovered trash bin.
Failure to Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all three units, the kitchen, and the main dining room. Observations revealed multiple lapses in hand hygiene practices, including staff not performing hand sanitization before and after resident contact, and residents not being provided hand hygiene before meals. Several wall-mounted hand sanitizer dispensers were found empty for extended periods, and staff did not consistently ensure their availability. Additionally, staff entered dietary areas without proper hair coverings or hand hygiene, and some staff admitted to forgetting these protocols due to being busy. Signage for Enhanced Barrier Precautions was missing outside rooms where it was required, and staff were observed providing care to residents on such precautions without wearing appropriate personal protective equipment (PPE). One resident with a suprapubic catheter, a condition requiring strict infection control, did not have the necessary signage posted, and the agency CNA providing care was not instructed on Enhanced Barrier Precautions. The Infection Control Nurse acknowledged gaps in the implementation of precaution signage and hand hygiene for residents receiving meals in their rooms. Interviews with staff, including the DON and Infection Control Nurse, revealed inconsistent understanding and application of infection control policies, particularly regarding when to use PPE and Enhanced Barrier Precautions. Plumbing issues led to shared bathrooms among residents and staff, further complicating infection control efforts. The Infection Control Nurse also stated that there were no infection control systems in place when assuming the role three months prior, and surveillance did not always catch missing signage or empty sanitizer dispensers.
Failure to Follow Physician's Orders and Provide Timely Incontinent Care
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for two residents. One resident, who had a physician's order for daily use of TED hose due to vascular insufficiency and hematoma, was observed with red, swollen legs and was not wearing the prescribed compression stockings. The resident reported not having worn TED hose for two weeks because their pair was destroyed in the washing machine. Agency staff assigned to the resident were unaware of the order, having relied on verbal handoff rather than reviewing the resident's care plan or Kardex. The Director of Nursing confirmed there was no policy in place regarding adherence to physician's orders. Another resident, with diagnoses including anxiety disorder, depression, schizophrenia, and hemiparesis, and who was consistently incontinent of bowel and bladder, did not receive timely incontinent care. The resident and their family reported extended waits for assistance, including an incident where the resident waited up to three hours for care after returning from church. Staff interviews revealed that delays were due to the need for two staff members to assist with mechanical lifts and a practice of waiting for the assigned CNA rather than seeking help from available staff. The LPN involved acknowledged instructing the resident to wait for care due to being busy and the assigned CNA being unavailable. The facility's care plans for both residents included interventions to anticipate and meet care needs, maintain cleanliness, and ensure comfort. However, staff failed to follow these plans, resulting in unmet care needs and non-compliance with physician's orders. The facility's No Pass Zone policy, which required all staff to respond to call lights, was not effectively implemented, contributing to the deficiencies observed.
Lack of Full-Time Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) or certified food service manager (CFSM) to oversee the food and nutrition service, as required. During an initial kitchen tour, it was observed that only two staff members were present, and both confirmed that there was no dietary manager or supervisor on site. Staff reported working independently without direct supervision or guidance from a qualified manager. Interviews with the CDM and facility administration revealed inconsistencies regarding the CDM's presence and role. The CDM stated he was responsible for three buildings and had not been present at the facility for the previous week, as he was assisting at other locations. He acknowledged that he had not had time to train or work closely with the dietary staff at this facility. The administrator initially claimed the CDM was full-time and present for 40 hours the previous week but later admitted uncertainty about the CDM's actual schedule after being informed of conflicting information from the CDM. Review of the job description for the dietary manager confirmed that the position was intended to be full-time and responsible for managing the dining services program, including staff supervision, training, and compliance with federal and state requirements. However, the CDM's own account and staff interviews indicated that these responsibilities were not being fulfilled due to the CDM's absence and divided attention across multiple facilities. This lack of consistent, qualified oversight had the potential to affect all residents receiving food and nutrition services.
Failure to Implement QAPI Action Plan for Environmental Repairs
Penalty
Summary
The facility failed to develop and implement an action plan to address and repair environmental deficiencies, impacting the safety and quality of life for all residents. Observations included fall mats with edges sticking up and significant rips, as well as nail holes in the wall next to a window. These environmental hazards were not addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process, despite being identified. Additionally, a resident reported having to use a bathroom down the hall for several months due to non-functioning toilets. Interviews with facility leadership confirmed that the QAPI Committee was aware of the issue with the toilets but had not developed a Performance Improvement Plan (PIP) to address it. The Corporate Executive acknowledged that repairs had been attempted but had not been discussed with the QAPI Committee, indicating a lack of coordinated action through the established quality assurance processes.
Failure to Maintain and Document Safe Operation of Patient Care Electrical Equipment
Penalty
Summary
The facility failed to maintain patient care electrical equipment in safe operating condition for a resident using an alternating pressure mattress. The facility did not have a policy regarding the maintenance of patient care electrical equipment, and there was no documentation available for the inspection or maintenance of the mattress. On observation, the resident was found lying in bed with the mattress, and reported having to sit in the lobby the previous day due to the mattress malfunctioning and feeling uncomfortable. The Corporate Executive confirmed that the Maintenance Director was unaware of the electrical testing requirement for the mattress, resulting in the absence of maintenance records.
Environmental Deficiencies and Poor Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable homelike environment for residents and staff, as evidenced by multiple environmental deficiencies observed during the survey period. Specific findings included cracked and exposed drywall, extensive paint chipping, unpainted patched holes, peeling paint in various colors, and black residue on ceilings and around air vents in several resident rooms and bathrooms. Furniture was also found to be in poor condition, such as a chest of drawers with extensive paint chipping, a deteriorated blue chair with worn fabric, and a bed footboard with a longitudinal crack. Additionally, a resident's manual wheelchair was observed with torn and damaged foam on the armrest. Bathrooms were noted to have thick black substances in the corners, peeling walls, and cracked door jams. Interviews with staff and residents confirmed ongoing issues, including unresolved plumbing problems that required staff and residents to share bathroom facilities. One resident reported that the poor wall conditions had persisted for a long time, with incomplete painting in their room. A corporate executive disclosed that the facility's owner had left the property, resulting in numerous unresolved concerns, including the ongoing plumbing issues. These observations and interviews collectively demonstrate the facility's failure to provide a safe, clean, and comfortable environment for its residents and staff.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents, R5 and R6, who were physically abused by R4. R4, who had a history of physical aggression and severe cognitive impairment, was admitted to the facility with diagnoses including paranoid schizophrenia and violent behavior. Despite having a care plan that identified R4's potential for physical aggression, the facility did not effectively prevent R4 from physically assaulting R5 and R6. R5, who had moderate cognitive impairment and a history of Alzheimer's disease and vascular dementia, was struck in the face by R4 over a misunderstanding regarding a wheelchair. This incident resulted in R5 sustaining a black eye and experiencing pain, which required medical attention. The facility's staff, including CNAs and an LPN, were present during the incident but were unable to prevent the assault. R5 expressed fear and discomfort following the incident, indicating a failure in the facility's ability to ensure a safe environment. R6, who had severe cognitive impairment and a history of hemiplegia and vascular dementia, was also physically assaulted by R4. This incident occurred after R6 allegedly called R4 a derogatory name, prompting R4 to punch R6 in the face. Although R6 did not sustain visible injuries, the incident highlights the facility's inability to manage R4's aggressive behavior effectively. The facility's failure to adequately monitor and address R4's known behavioral issues contributed to these incidents of resident-to-resident abuse.
Failure to Investigate Mechanical Lift Incidents
Penalty
Summary
The facility failed to conduct a complete and thorough investigation for a resident who experienced two falls from a mechanical lift. The first incident occurred when the sling strap broke during a transfer from the bed to a wheelchair, resulting in the resident hitting their head on the wheelchair arm. This incident led to a concussion and cervical strain, as confirmed by an emergency department visit. Although staff involved in this incident received re-education on mechanical lift safety, there was no evidence that all relevant staff, including those involved in the second incident, received similar training. The second incident involved the same resident falling when the shower harness strap broke during a transfer from a shower chair to the bed. The CNA involved attempted to brace the resident with their leg to prevent injury. Despite this effort, the resident sustained a bruise and a skin tear. There was no documented investigation for this incident, and the CNA involved had not received re-education on mechanical lift safety following the first incident. The resident involved had a medical history of traumatic brain injury, hemiplegia, and muscle weakness, which increased their risk of falls. The facility's policies required that all injuries be investigated and that only trained personnel operate mechanical lifts. However, the facility did not adhere to these policies, as evidenced by the lack of a documented investigation for the second incident and incomplete staff re-education following the first incident.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide treatment and services to prevent and/or heal a resident's pressure ulcers, resulting in the resident acquiring multiple pressure ulcers. The resident, who had severe cognitive impairment and was receiving hospice care, was admitted with diagnoses including vascular dementia, chronic obstructive pulmonary disease, and hyperlipidemia. Despite being at high risk for skin breakdown due to immobility and incontinence, the facility did not adhere to its own policies for skin and wound management and repositioning, leading to the development of multiple pressure ulcers on the resident's body. The facility's records revealed that the resident had several deep tissue injuries and unstageable wounds that were not properly treated as per physician orders. The Medication Administration Record and Treatment Administration Record indicated that wound care treatments were not consistently administered. Interviews with the Director of Nursing and other staff members revealed a lack of proper documentation and execution of turning and repositioning protocols. Additionally, there was a discrepancy between the facility's claim that the family had refused wound care and the family's statement that they wanted all comfort measures, including wound care, to be provided. The hospice staff also reported that the resident was not being turned regularly and that they were not in the facility daily to change dressings as ordered. This neglect was reported to various authorities, leading to the discovery of the resident's untreated wounds. The facility's failure to follow its own policies and physician orders for wound care and repositioning directly contributed to the resident's deteriorating condition and the development of multiple pressure ulcers.
Removal Plan
- The CEO/Nurse met with the Agape Nurse to ensure treatments for residents under their care were being documented in the hospice notes and the staff of the facility will complete on days they are not in the facility.
- All residents had a head-to-toe assessment completed by licensed nurses. All identified areas were provided treatment if warranted. The attending physician and resident's representative were notified.
- All residents will have a head-to-toe skin assessment upon admission and weekly skin assessment thereafter. All current residents will have a weekly skin assessment completed to ensure the skin remains intact.
- All licensed and certified staff will be educated on ensuring residents preventative measures are in place for wound care to include: 1. Weekly Skin Assessment and prevention. 2. Shower Skin Audit (completed by C.N.A.). 3. New Admission Skin Assessment and prevention. 4. Turning and repositioning. 5. Abuse and Neglect.
- Licensed nurses were educated on the protocol for identifying risk and wounded residents and ongoing to include notifying the MD and RR.
- The Director of Nursing or designee will audit the treatments weekly to ensure the residents have been provided proper wound care treatment per the MD order.
- The Director of Nursing will review the audit with the administrator to ensure the protocol is being followed.
- The Administrator and DON will review the completed weekly skin audits with the monthly QAPI Committee for further follow-up and recommendations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a history of exit-seeking behavior and was at risk for elopement, successfully left the facility. The incident occurred when door exit alarms were triggered, and the resident was found outside the facility, approximately 200 feet away, ambulating with a rollator walker. The resident was appropriately dressed for the weather and was returned to the facility without injuries. However, the resident continued to exhibit exit-seeking behavior and required constant redirection and 15-minute checks to ensure safety. The resident's care plan indicated a risk for elopement due to cognitive impairment, but the interventions in place were insufficient to prevent the elopement. The care plan had been updated multiple times, but the resident's exit-seeking behavior persisted. The facility's policy on wandering and unsafe residents aimed to prevent elopement while maintaining a least restrictive environment, but the staff failed to adequately supervise the resident and prevent the elopement. Interviews with staff revealed that the resident frequently exhibited exit-seeking behavior and required constant reminders and redirection. On the day of the elopement, staff initially thought the alarm was from a different door, leading to a delay in locating the resident. The Director of Nursing was informed, and the resident was placed on 15-minute checks. The facility's failure to provide adequate supervision and timely response to the alarm resulted in the resident's successful elopement, constituting Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident 1 was escorted back into the facility and assessed without injury, placed on 15-minute checks, MD and RP notified. The elopement assessment was revised with a score of 4 indicating at risk for elopement and the care plan was updated with the new assessment information.
- All egress doors were checked by the Maintenance Director after the elopement and all doors were working properly.
- The DON and Unit Coordinator are completing the wandering and elopement assessment on all residents. Any change in elopement status will be care planned, and the MD and RR notified.
- The Director of Nursing and Administrator were educated on the Elopement Resource manual and Elopement Policy and Procedure by the CEO who is a licensed nurse, Social Worker and LNHA.
- All departments will be educated on the Elopement Resource manual and Elopement Policy and Procedure by the Administrator and Director of Nursing.
- The Elopement Resource Manual and Elopement Policy and Procedure Education will be included in the new hire orientation.
- The maintenance or designee will audit the door daily and Manager on Duty on the weekend to ensure the egress doors are in good repair and enunciate correctly. The Administrator will review the completed audits for further follow-up if warranted.
- The Plan of Correction for F689 was reviewed with the QAPI Committee to include the Medical Director without changes.
- The completed audits and identified listing of residents that are at risk of elopement will be reviewed monthly in the QAPI committee for further follow-up and recommendations.
Failure to Ensure Annual CNA Training
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) received the minimum 12 hours of annual training as required. The facility's policy mandates that nurse aides must undergo a state-approved training program and participate in a state-approved training and competency evaluation program. During an interview, the Administrator, who was new to the facility, was unable to provide documentation supporting that the four CNAs had completed the required training. Despite efforts to contact the agency for supporting training documents, the necessary documentation was not available at the time of the survey.
Failure to Complete and Review Weekly Body and Treatment Audits
Penalty
Summary
The facility failed to ensure weekly body audits were completed on all residents and further failed to ensure the weekly treatment audits were completed as stated in the plan of correction. No documentation was found to confirm that the weekly skin and treatment audits were reviewed by the QAPI Committee. During interviews with the Administrator, Administrator in Training, and the Director of Nursing, it was confirmed that the weekly body audits were not being completed, and there was no documentation to ensure the treatments were audited and completed as required.
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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