F0835

F

Failure to Administer Resources Leading to Interruptions in Food, Oxygen, and Linen Services

Ridgeway, South Carolina Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources, resulting in interruptions to food service, oxygen supply arrangements, linen availability, and an incomplete facility assessment. Surveyors reviewed the facility’s undated and unsigned Business Continuity policy, which stated that critical resources would be identified, contracts with two or more vendors would be maintained, and emergency supplies would be stored at established par levels. The policy also called for ongoing evaluation of communication, resources, utilities, staff, food and water, and safety and security when sheltering in place. A separate undated and unsigned Compliance and Ethics Program policy stated that the facility would assign high-level personnel to oversee compliance, ensure sufficient resources and authority to assure compliance, and review the program annually to promote quality care.

During the kitchen tour, surveyors observed that more than 90% of products in the freezer, cold, and dry storage areas bore a food delivery date corresponding to the day of survey, while photos taken earlier that morning by the Dietary Manager showed those same storage areas empty or nearly empty, with between zero and four items. The Administrator and ADON acknowledged that the survey was likely related to food delivery issues and stated this was the second time food delivery had been cut off for nonpayment, with the facility’s U.S. Foods account suspended and two scheduled deliveries missed. The Dietary Manager reported that this was actually the third such occurrence, that food deliveries normally occurred twice weekly, and that the last delivery before the suspension had been on a date when the account was subsequently cut off, causing missed orders. Receipts showed that menu items had to be purchased from local vendors, and payment records from U.S. Foods documented repeated large lump-sum payments made after multiple past-due charges had accumulated, with the account being suspended for nonpayment on multiple occasions.

In the laundry area, surveyors observed covered racks of clothing awaiting distribution and bins of personal clothing to be folded, but no linens awaiting distribution and no emergency linen supply. Dirty linens were present in bins awaiting laundering. Invoices from a linen and medical supply vendor showed multiple orders for towels, washcloths, and sheets with 30‑day payment terms over several months, with unclear payment status. The Medical Supplies Clerk stated that ordered items frequently did not arrive because invoices had not been paid, that she would be told by vendors that payment was needed before further orders could be filled, and that this occurred several times per year. She reported that when supplies could not be ordered, items were sometimes obtained from local stores or online, and that the facility had gone through several vendors because bills were not paid.

Surveyors also reviewed communications with the oxygen supplier, which showed the facility’s account placed on hold for being over the credit limit on multiple dates, with attached accounting statements. The Medical Supplies Clerk indicated she was responsible for central supply, including linen inventory and ordering medical supplies, and that outstanding invoices were reported to the Accounts Payable person. The Regional Director of Operations stated that the facility did not have a governing board, that the owner was the 100% owner, and that the corporate entity was considered the governing body. He described the owner as difficult to reach and personally signing checks, and he acknowledged that staff should not have had to worry about feeding residents or having enough supplies, and that lack of necessary supplies could affect morale and patient care. The Administrator reported that corporate cards used to purchase food and supplies were sometimes maxed out, that she did not know how much would be placed on the cards, and that although the owner “pulled them out at the last minute,” she was not confident they could get through an emergency.

Review of the facility assessment showed it was undated, unsigned, and had been reviewed with the QAA Committee on a prior date, but several sections were blank or incomplete and lacked supporting documentation. A Profit & Loss Budget Overview for a recent month showed a negative net income. When asked about corporate compliance documents, bylaws, or operating policies, the RDO stated there were no bylaws or operating policy, that continuity of business was based on disaster preparedness, and that policies came from an external compliance store. Despite the posted corporate sign in the foyer emphasizing stewardship and improving quality of life, interviews and document reviews demonstrated repeated interruptions in critical vendor services for food, linens, and oxygen due to nonpayment or credit issues, and an incomplete facility assessment, all reflecting failures in the administration of the facility’s resources and compliance structures as observed by surveyors.