Riverside Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, South Carolina.
- Location
- 2375 Baker Hosp Blvd, Charleston, South Carolina 29405
- CMS Provider Number
- 425082
- Inspections on file
- 20
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Riverside Health And Rehab during CMS and state inspections, most recent first.
Surveyors found that food items in the refrigerator were not labeled or dated, dry storage bins for sugar and flour contained Styrofoam cups in direct contact with food instead of proper scoops, and dirty trays and food debris were present in the kitchen prep area. The oven was observed to have thick grease and food debris, and staff interviews confirmed lapses in labeling, dating, and cleaning procedures.
Three residents with upper extremity contractures did not receive hand splinting as recommended by OT, due to missing orders, lack of care plan updates, and poor communication between therapy and nursing. Observations showed splints not in use and staff unaware of splinting needs, despite documented recommendations and physician orders.
The facility did not ensure resident dignity by serving meals in Styrofoam containers to most residents due to unwashed kitchenware, and failed to protect a resident's physical privacy during medication administration when an LPN left the door open and did not use the privacy curtain, making the resident visible from the hallway.
Two cognitively intact residents were observed with medications left unattended at their bedside without proper assessment or authorization for self-administration, contrary to facility policy. An LPN and RN confirmed that no residents had been assessed for self-administration, and staff interviews revealed that some residents also kept or ordered their own over-the-counter medications, which were not consistently monitored or removed.
Surveyors observed an uncovered and overflowing garbage container near the food preparation area, with paper towels and gloves on the floor. The Dietary Manager confirmed this was unacceptable and that garbage should be contained or emptied before overflowing.
An LPN was observed carrying unbagged soiled linen out of a resident's room and placing it in a laundry cart, contrary to facility policy requiring soiled linen to be bagged before removal. The resident was on Enhanced Barrier Precautions due to an enteral feeding tube and had a history of UTI and dysphagia. Staff interviews confirmed the expectation that soiled linen should be bagged to prevent infection spread.
The facility did not update its daily nurse staffing posting, displaying outdated information in a common area accessible to residents and visitors. Both the Assistant Administrator and DON confirmed the posting was not current and should have reflected the actual staffing for the day.
A resident with moderate cognitive impairment was mistakenly taken by a transport company, and the facility failed to identify the resident as missing or implement emergency protocols in a timely manner. Staff assumed the resident was visiting friends, and it was not until the resident missed medications and dinner that his absence was noted. The resident was later found at a local Waffle House and returned to the facility.
A resident with moderate cognitive impairment eloped from the facility due to inadequate supervision and communication failures. The resident was mistakenly taken by a transport company instead of the intended resident, and staff did not realize the resident was missing until later. The facility failed to report the incident promptly, and the resident was eventually found by police at a local Waffle House.
The facility did not conduct smoking assessments for 4 out of 10 residents who smoke and failed to enforce safety protocols for all 10 residents. Observations revealed residents smoking across a busy street without supervision or safety equipment. Residents expressed concerns about safety and admitted to keeping smoking materials on their person, contrary to facility policy. Medical records indicated specific risks for residents with conditions like COPD and chronic bronchitis, increasing the hazard of unsupervised smoking. Staff interviews highlighted a lack of awareness and oversight regarding smoking assessments and protocols, contributing to the identified deficiency.
The facility failed to provide clean linen and washcloths to residents, as evidenced by multiple observations of stained, dirty, or missing linens in several rooms. Residents expressed ongoing frustration over the issue, which had been discussed in Resident Council Meetings for several months without resolution. The DON acknowledged the problem, attributing it to an outsourced laundry service, and stated that laundry services would be conducted in-house starting next month.
The facility failed to provide sufficient RN staffing on a 24-hour basis, with multiple days in December, January, and February lacking the required RN coverage. Staff members reported challenges in providing adequate care due to insufficient staffing, and the DON acknowledged the issue, stating that they or the ADON would step in to assist when needed.
The facility failed to ensure proper labeling and storage of medications and biologicals, with observations revealing unlabeled and expired medications, loose pills, and improper storage practices in multiple medication carts and storage rooms. Staff interviews indicated a lack of awareness and adherence to protocols.
The facility failed to ensure that a resident was afforded the right to formulate an advance directive. Despite the resident's significant health issues, the facility did not follow its policy to provide information and document any existing directives. This deficiency was confirmed when the DON was unable to locate any advance directive for the resident.
The facility failed to ensure that a resident or his personal representative received discharge notification in writing and in a language they could understand upon discharge to the hospital. Additionally, the facility did not ensure that the state Ombudsman received a copy of the notification in a timely manner. The resident had multiple diagnoses and was hospitalized for several days. The Director of Nursing confirmed the lack of proper documentation in the medical record and incomplete information provided to the Ombudsman.
The facility failed to implement fall prevention interventions for a resident at risk for falls due to multiple medical conditions. Observations revealed improperly positioned fall mats, which were confirmed by an LPN and the DON. Despite the care plan and facility policies emphasizing proper placement of assistive devices, the facility did not ensure adherence, leading to a deficiency in care.
The facility failed to provide adequate nail care, maintain personal hygiene, and offer showers to a resident requiring extensive assistance with ADLs. Observations and interviews revealed that the resident had long, dirty fingernails and significant facial hair, and was not regularly offered showers. Staff inconsistencies in providing and documenting ADL care contributed to the deficiency.
A resident with multiple diagnoses, including osteomyelitis and wound botulism, received improper wound care from an LPN, who failed to follow the facility's wound care procedures. The LPN did not cleanse the wound correctly, used the same gauze for different areas, and did not change gloves appropriately, potentially compromising the resident's healing and increasing infection risk.
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in an 8 percent error rate. Insulin was administered incorrectly to two residents due to improper priming and administration techniques by LPNs.
Deficient Food Storage, Equipment Cleanliness, and Sanitation in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's dietary services, including improper food storage, unclean equipment, and unsanitary practices. During kitchen tours, food items such as gravy, roast beef, opened cheese, and sliced sandwich meats were found in the refrigerator without labels or dates. Large bins containing sugar and flour had Styrofoam cups in direct contact with the food, rather than proper scoops. Additionally, dirty trays were stored on a rack in the prep area, and crumbs and scraps of paper were found on the floor. The oven's cooktop and sides were coated with thick grease and food debris, indicating a lack of regular cleaning. Interviews with dietary staff revealed a lack of awareness regarding the use of Styrofoam cups as scoops and confirmed that proper procedures for labeling, dating, and cleaning were not followed. The Dietary Manager acknowledged that staff should have labeled and dated food, that Styrofoam cups should not be used in dry food bins, and that the oven should have been cleaned. The facility was unable to provide a kitchen cleaning and service policy when requested by surveyors. These deficiencies had the potential to affect a significant number of residents who received meals prepared in the facility.
Failure to Implement Therapy Recommendations for Hand Splints in Residents with Contractures
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for the use of hand splints for three residents with contractures. For one resident with cerebral palsy and quadriplegia, the OT discharge summary recommended use of a left hand splint for three hours daily to prevent worsening contractures. However, there were no corresponding orders or care plan updates in the electronic medical record (EMR), and the resident reported that after therapy services ended, no one assisted with applying the splint, which was observed unused in the room. Another resident with a right hand contracture had OT recommendations for continued use of a right hand splint, but the care plan did not address this intervention, and no orders or treatments were found in the EMR. Observations showed the resident's hand contracted and the splint not in use, with staff interviews confirming a lack of follow-through on therapy recommendations after discharge from rehabilitation services. The Director of Nursing (DON) and Rehabilitation Director acknowledged communication failures between nursing and therapy regarding the implementation of splinting orders. A third resident with a right hand contracture and severe cognitive impairment had a physician order and care plan interventions for daily splinting, but observations revealed the resident was not wearing a splint, and staff were unaware of the need. The occupational therapist confirmed the resident should have a palm guard, but it was not found in the room, and staff reported using a towel instead. Interviews with facility leadership confirmed gaps in documentation, communication, and implementation of splinting interventions as recommended by therapy.
Failure to Ensure Resident Dignity and Privacy During Meal Service and Medication Administration
Penalty
Summary
The facility failed to promote residents' rights to dignity and privacy in two key areas. For 128 out of 147 residents, meals were served in Styrofoam containers during breakfast and lunch on two consecutive days. This occurred because the kitchen staff arrived to find dirty pots, pans, and dishes from the previous evening and did not have sufficient time to clean them before meal service. The Dietary Manager confirmed that serving meals in Styrofoam containers was not acceptable and that the kitchen should have been properly cleaned and prepared by the previous shift. The facility's policy on resident rights, which was undated, states that residents are to be protected and promoted in their rights, including privacy and dignity. Additionally, a resident with a history of congestive heart failure and neuromuscular dysfunction of the bladder, who was cognitively intact, did not have their right to physical privacy protected during medication administration. An LPN administered insulin and performed a suprapubic catheter irrigation with the resident's door left wide open and the privacy curtain not drawn, making the resident visible from the hallway. The LPN stated the door was left open to monitor an unlocked medication cart and laptop, but acknowledged that normally the privacy curtain would be used. Both the RN and DON confirmed that staff are expected to always provide privacy during patient care, with no exceptions.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents' ability to self-administer medications and did not follow its own policy regarding medication administration. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, a medication cup containing eight medications was left unattended on the overbed table. The resident, who was cognitively intact per a recent BIMS assessment, stated she had fallen asleep and forgot to take the medications, and then proceeded to take them after being prompted. The LPN confirmed she had left the medications and had not observed the resident taking them, and also acknowledged that the resident had not been assessed for self-administration, which was not in line with facility policy. Another cognitively intact resident with a history of congestive heart failure was observed to have a medicine cup with 13 pills left on the bedside table by an LPN, who stated that the resident preferred to take medications with breakfast and that she would return to check if the medications were taken. The resident also had a bottle of Tums at the bedside, which he reported purchasing himself and using as needed, and stated that the physician had seen the bottle but had not commented. The LPN and RN both confirmed that there was no assessment for self-administration for this resident, and that facility policy did not allow medications to be left at the bedside. Facility policy required that residents may self-administer medications only after an assessment by the Interdisciplinary Care Team, but neither resident had such an assessment or order in place. Staff interviews confirmed that medications were not to be left unattended and that there were no residents currently assessed to self-administer medications. The facility also reported that some residents order their own over-the-counter medications, which staff monitor and remove as needed. These actions and inactions resulted in a failure to assess and authorize self-administration of medications, contrary to facility policy and regulatory requirements.
Improper Disposal of Kitchen Garbage
Penalty
Summary
During an initial kitchen tour with the dietary cook, surveyors observed that the garbage container near the food preparation area was uncovered and overflowing, with additional garbage such as paper towels and gloves scattered on the floor. This unsanitary condition was directly observed in the kitchen, where meals are prepared for residents. In a subsequent interview, the Dietary Manager acknowledged that the situation was unacceptable and confirmed that garbage should be contained or emptied before reaching an overflowing state. The deficiency was limited to the improper disposal and containment of garbage in the kitchen area, as evidenced by the overflowing container and waste on the floor, with no mention of specific residents' medical histories or conditions at the time of the deficiency.
Improper Handling of Soiled Linen by Staff
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to properly handle soiled linen after providing activities of daily living (ADL) care to a resident. The LPN exited the resident's room carrying a large bundle of unbagged soiled linen and placed it in the laundry cart located 60 to 75 feet away from the room. This action was in direct violation of the facility's policy, which requires soiled linen to be minimally handled and placed in a collection bag before being removed from a resident's room. The LPN confirmed during an interview that the linen was not bagged as required by facility procedures. The resident involved had been readmitted with diagnoses including a urinary tract infection (UTI) and dysphagia, and was on Enhanced Barrier Precautions due to an enteral feeding tube. Interviews with other staff, including a Certified Nurse Aide (CNA) and the Infection Preventionist (IP), confirmed that the facility's expectation and policy is for all soiled linen to be bagged prior to removal from a resident's room to prevent the spread of infection. The failure to follow this protocol was observed and acknowledged by staff.
Failure to Post Current Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post current nurse staffing information daily as required. On review of the 24-hour nurse staffing posting in the front lobby, the information displayed was dated three days prior to the date of review and did not reflect the current staffing levels. During interviews, both the Assistant Administrator and the Director of Nursing confirmed that the posting was outdated and acknowledged that the staffing data should be current, accurate, and updated daily.
Failure to Identify Missing Resident and Implement Emergency Protocols
Penalty
Summary
The facility failed to identify and acknowledge that a resident was missing, which led to a delay in implementing emergency protocols to locate the resident. The resident, who had moderate cognitive impairment and was at risk of elopement, was last seen sitting in his wheelchair on the front porch of the facility. Staff assumed the resident was visiting friends within the facility, and it was not until the resident missed his afternoon medications and dinner that staff realized he was missing. The facility did not report the resident as missing to the Administrator or the police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding the resident's whereabouts. The Medical Records Clerk discovered that the transport company had mistakenly taken the resident instead of the intended individual, but this information was not promptly communicated to the facility's leadership. The Central Supply Clerk, who was covering the receptionist's lunch break, noticed transport vans but did not see anyone board them. The LPN on duty did not receive a report or notice anything unusual until a CNA mentioned the resident's untouched dinner tray. The Director of Nursing and Assistant Director of Nursing were unaware of the resident's absence until later in the day. The resident was eventually found at a local Waffle House, where he had informed workers that he wanted to go home. The police were contacted, and the resident was returned to the facility. Interviews with the Administrator and Social Services Director revealed confusion regarding the resident's decision-making capacity, as there was conflicting information in the medical records.
Removal Plan
- Resident #1 left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident #1 is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for.
- Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch
- Re-education for staff on Abuse, Neglect, or Mistreatment
- Re-education for staff on physically checking on residents at least every two hours
- Continue a midnight census every night as a daily audit.
- Safe area (courtyard) provided for residents to socialize. Residents informed.
- Adhoc QAPI
- ADON/designee will audit midnight census five times weekly x4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R3, who successfully eloped from the facility. R3, who had been admitted with diagnoses including depression, cognitive communication deficit, and unspecified psychosis, had a BIMS score indicating moderate cognitive impairment. On the day of the incident, R3 was last seen sitting in his wheelchair on the front porch after lunch, which was his usual routine. However, R3 was not available for his afternoon medications or dinner, and staff assumed he was visiting friends within the facility. The facility did not report R3 as potentially missing to the Administrator or the Police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding R3's whereabouts. The Medical Records Clerk noted a discrepancy with the transport company, which had mistakenly taken R3 instead of the intended resident. The Central Supply Clerk, covering the Receptionist's lunch break, observed transport vans but did not see anyone board them. LPN1, who was on duty, did not receive a report and was unaware of R3's absence until a CNA noted R3's untouched dinner tray. The DON confirmed that R3 left with transport instead of the intended resident, and a Code White was not initiated as it was not known that a resident was missing. The Administrator was not informed of the incident until the following day when R3 was returned to the facility by police after being found at a local Waffle House. The Administrator expressed that had she been aware of the situation, she would have initiated a lockdown and conducted a headcount. The SSD admitted to a lack of documentation regarding R3's decisional making capacity, contributing to the confusion in R3's medical record. The facility's failure to adhere to its elopement policy and ensure proper supervision and communication led to the resident's elopement.
Removal Plan
- Resident left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when resident returned to the facility. All residents were accounted for.
- Elopement drill conducted.
- Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch.
- Re-education for staff on Elopement Policy and Process and Abuse, Neglect, or Mistreatment.
- Elopement risk assessments completed on residents who reside in the facility.
- A review of residents who are assessed as an elopement risk was completed and care plans updated as appropriate.
- Safe area (courtyard) provided for residents to socialize. Residents informed.
- Adhoc QAPI.
- Continue a midnight census every night as a daily audit.
- ADON/designee will audit for elopement assessments completed and accurate within 24 hours or admission/readmission five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
- ADON/designee will audit 24-hour report and new nurses' notes (facility activity report) for documentation of elopement risks five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
- Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.
Smoking Safety Protocols and Assessments Deficiency
Penalty
Summary
The facility failed to conduct smoking assessments for 4 out of 10 residents who smoke and did not provide proper safety protocols for all 10 residents who smoke. During observations, it was noted that residents were smoking across the street from the facility without proper supervision or safety equipment. Interviews with residents revealed that they were crossing a busy street to smoke, expressing concerns about the lack of safety in doing so. Some residents mentioned keeping smoking materials on their person at all times, indicating a potential hazard. The facility's policy stated that smoking materials should be stored in assigned lockers, but this was not being enforced or monitored effectively. Review of individual residents' medical records highlighted specific risks and conditions that made smoking without proper supervision particularly hazardous. For example, Resident R80 had diagnoses including acute respiratory disease and COPD, while Resident R133 had chronic bronchitis and was identified as an unsafe smoker due to respiratory distress risk. These medical conditions, combined with the lack of proper smoking assessments and safety protocols, increased the potential for accidents and harm to these residents. The failure to address these risks in a timely manner contributed to the deficiency identified during the survey. Interviews with staff members revealed a lack of awareness regarding the smoking assessments and safety protocols for residents who smoke. Staff mentioned that residents were required to sign out to smoke but were not consistently monitored or supervised during this time. The facility's leadership acknowledged that they were not fully aware of the extent of residents smoking or the potential hazards associated with it. This lack of oversight and enforcement of smoking policies, combined with residents' behaviors and medical conditions, created an environment where accidents and safety risks were not adequately addressed.
Failure to Provide Clean Linens and Washcloths
Penalty
Summary
The facility failed to provide clean linen and washcloths to residents throughout the facility. This deficiency was identified through interviews, record reviews, and multiple observations. The Resident Council Meeting Minutes from September 2023 to February 2024 consistently revealed concerns about the lack of linens and washcloths. Observations on 03/12/24 and 03/13/24 showed that several rooms had stained, dirty, or soiled linens, and some beds had no linens at all. Residents were found lying directly on mattresses, and rooms had unpleasant odors, indicating a severe lapse in maintaining a clean and comfortable environment for the residents. During the Resident Council Meeting on 03/13/2024, residents expressed their frustration over the ongoing issue of linen shortages, stating that the problem had been discussed at every meeting without resolution. The Director of Nursing (DON) acknowledged the issue, attributing it to the outsourced laundry service, which was not providing timely and complete returns of laundered items. The DON mentioned that the contract with the outsourced company would be terminated at the end of the month, and all laundry services would be conducted in-house starting 04/01/24. However, the deficiency persisted at the time of the survey, affecting the residents' right to a safe, clean, and comfortable environment.
Insufficient RN Staffing
Penalty
Summary
The facility failed to provide sufficient Registered Nurse (RN) staffing on a 24-hour basis to ensure all residents receive adequate care. The facility's policy requires RN coverage for at least eight consecutive hours, seven days a week. However, the review of the Staffing Daily Posting revealed multiple days in December 2023, January 2023, and February 2023 where the facility did not meet this requirement. Specifically, there were six days in December, nine days in January, and thirteen days in February without the required RN coverage. This deficiency was confirmed through observations, interviews, and record reviews conducted by the surveyors. During interviews, staff members, including a Certified Nurse Assistant (CNA) and a Licensed Practical Nurse (LPN), reported challenges in providing adequate care due to insufficient staffing. The CNA mentioned that the number of residents they care for depends on the number of staff call-ins, and they often have to team up to provide care. The LPN stated that they communicate residents' concerns during huddles and inform the RN or Director of Nursing (DON) in case of emergencies. The DON acknowledged the staffing issues and mentioned that they or the Assistant Director of Nursing (ADON) would step in to assist when there is no RN on duty. Despite these efforts, the facility did not consistently meet the required RN staffing levels, leading to the identified deficiency.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed in multiple medication administration carts and storage rooms. Specifically, medications were found without open dates, loose pills were present in medication carts and narcotic lockboxes, and expired medications and biologicals were not removed from storage areas. For instance, in the medication storage room on Hall 300, items such as an open Luer Lock Disposable syringe and a bag of IV caps not in original packaging were found. Additionally, the refrigerator contained an unlabeled syringe and the floor was dirty with spills. In the treatment supply room on Hall 300, several items were improperly stored or expired, including hydrogen peroxide stored in a box labeled for non-woven drain sponges and a urological catheter strap in an open package. Similarly, the central supply room on Hall 200 contained expired suture removal trays and an open pack of cotton tip wood applicators. Loose pills and unlabeled medication pens were also found in medication carts on Halls 100 and 400, with some items lacking open dates, making it impossible to determine their expiration. Interviews with staff, including LPNs and the Central Supply Clerk, revealed a lack of awareness and adherence to proper medication storage protocols. The Director of Nursing (DON) indicated that medication storage rooms are managed by unit managers and the Central Supply Clerk, with monthly checks, while medication carts are managed by the nursing staff. However, the observations indicated that these checks were not effectively ensuring compliance with proper storage and labeling practices, leading to the deficiencies noted in the report.
Failure to Ensure Resident's Right to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was afforded the right to formulate an advance directive. The facility's policy on advance directives outlines specific procedures to be followed upon a resident's admission, including providing information about advance directives, obtaining signatures, and documenting any existing directives in the resident's medical and financial records. However, a review of R30's electronic medical record revealed no documentation of advance directives or any indication that R30 or his personal representative was given the opportunity to formulate one. This deficiency was confirmed during an interview with the Director of Nursing, who was unable to locate any advance directive for R30. R30 was admitted to the facility with multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. Despite these significant health issues, the facility did not follow its own policy to ensure that R30's rights regarding advance directives were upheld. This oversight indicates a failure in the facility's admission process and documentation practices, directly impacting the resident's right to make informed decisions about their care.
Failure to Provide Discharge Notification
Penalty
Summary
The facility failed to ensure that a resident or his personal representative received discharge notification in writing and in a language they could understand upon discharge to the hospital. Additionally, the facility did not ensure that the state Ombudsman received a copy of the notification in a timely manner. This deficiency was identified during a review of the facility's policy, record reviews, and interviews. The facility's policy requires that residents and their representatives be notified of transfers or discharges in writing and in a language they understand, and that a copy of the notice be sent to the state Ombudsman. However, the review of the resident's electronic medical record revealed no documentation to confirm that these notifications were made. The resident in question had multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. The resident was hospitalized from March 2 to March 6, 2024. During an interview, the Director of Nursing confirmed that the medical record did not contain a copy of the transfer paperwork given to the resident or the resident's representative. The documentation provided to the Ombudsman was also incomplete, lacking specific resident information such as names and dates of discharge.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement the interventions outlined in the care plan for Resident 53, who was at risk for falls due to multiple medical conditions including encephalopathy, seizures, and impaired mobility. The care plan specified the use of fall mats and ensuring the call light was within reach. However, during observations, the fall mats were found to be improperly positioned, with one mat diagonally under the bed and the other near the wall with a folding chair on top of it. This improper placement of fall mats was confirmed by both an LPN and the Director of Nursing (DON), who acknowledged that the mats should be beside the bed and the call light within reach to prevent falls. The DON also mentioned that Resident 53 sometimes places herself on the floor, which is noted in the care plan, but the expectation is that staff adhere to the care plan to keep the resident free from falls. The deficiency was identified through a review of the facility's policies and Resident 53's care plan, as well as direct observations and staff interviews. The facility's policies on care planning and fall management emphasize the need for individualized interventions and proper placement of assistive devices to prevent falls. Despite these policies, the facility did not ensure that the fall mats were correctly positioned, thereby failing to meet the professional standards of quality care as outlined in their own policies. This lapse in care was observed on multiple occasions, indicating a systemic issue in adhering to the care plan for Resident 53.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate nail care, maintain personal hygiene, and offer showers to a resident requiring extensive assistance with Activities of Daily Living (ADLs). The facility's policy mandates that necessary care be provided to all residents unable to perform ADLs independently. However, observations and interviews revealed that Resident 44, who has severe cognitive impairment and multiple medical conditions, did not receive proper nail care or regular showers. The resident's ADL Point of Care history indicated that he was only given a bath on eight out of twenty-nine days, with no option for a shower on seven of those days. Observations showed that the resident had long, dirty fingernails and significant facial hair, which he expressed dissatisfaction with during an interview. He also mentioned not being provided with a razor to shave his face and not being offered a shower. Interviews with staff members, including CNAs and LPNs, revealed inconsistencies in the provision and documentation of ADL care. CNA2 admitted to not providing any showers on the day of the interview and was unable to locate the documentation book for showers. CNA3 mentioned needing to ask a nurse before cutting the nails of diabetic residents, while LPN5 stated that personal hygiene tasks should be checked and addressed during morning care. The Director of Nursing (DON) confirmed that residents should be cleaned daily and that ADL care should include nail and personal hygiene. The DON also mentioned that showers should follow a schedule, but there was no documentation to indicate whether residents received a bed bath or a shower. Further interviews with other staff members, including CNA4 and LPN1, highlighted that personal hygiene care should be documented daily and that showers are typically provided between 8 am and 11 am. The Administrator confirmed that ADL care is provided throughout the day and that staff are educated on ADL care during orientation and ongoing training. However, the Administrator was only recently made aware that residents were not being offered showers according to their preferences. The lack of proper documentation and adherence to ADL care protocols led to the deficiency in providing adequate care for Resident 44.
Improper Wound Care Procedures
Penalty
Summary
The facility failed to follow proper wound care procedures for a resident, identified as R85, who was admitted with diagnoses including osteomyelitis of the vertebra, sacral and sacrococcygeal region, protein-calorie malnutrition, and wound botulism. During an observation of wound care performed by an LPN with a CNA assisting, several procedural errors were noted. The LPN did not cleanse the wound in a circular motion as required, used the same gauze to blot both the wound bed and the surrounding tissue, and did not change gloves appropriately between tasks. Additionally, the soiled dressing was saturated and not dated or initialed, and the bed beneath the chux was also saturated and stained with drainage, indicating improper wound management and infection control practices. The LPN confirmed during an interview that she had not correctly performed the wound care, acknowledging the improper use of gauze and gloves. The facility's policy on wound care states that pressure ulcers should be treated in accordance with professional standards to promote healing and prevent infection. However, the observed actions did not align with these standards, potentially compromising the resident's wound healing process and increasing the risk of infection.
Medication Administration Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in an 8 percent error rate. Specifically, insulin administered via an insulin pen was primed incorrectly and administered incorrectly for Resident 100. The Licensed Practical Nurse (LPN) held the pen horizontally and did not confirm the insulin escaping the needle. Additionally, the LPN did not hold the pen in the resident's skin for the required 10 seconds after pressing the dose button, removing it within 3 to 4 seconds instead. During an interview, the LPN confirmed the incorrect priming method and claimed to have counted to 10 before removing the needle, which was not observed to be true. Another instance involved LPN3 preparing to administer insulin to Resident 14. LPN3 also primed the insulin pen incorrectly by holding it horizontally and could not confirm that insulin had escaped the needle before administration. These actions led to the facility failing to meet the required medication administration error rate, as the incorrect priming and administration of insulin were observed in 2 out of 25 opportunities for error.
Latest citations in South Carolina
A resident with dementia, severe cognitive impairment, wandering behavior, and documented elopement risk eloped after staff failed to adequately respond to an exit-door alarm and did not promptly recognize the resident was missing. The resident, who required close supervision and was on 30-minute checks for wandering, was last seen ambulating in the facility before a dining room/fire exit alarm sounded; dietary staff briefly checked, saw no one, silenced the alarm, and returned to work without initiating a facility-wide missing-resident response. Later, when the resident did not appear for dinner, staff began searching and learned from a staff member driving home that someone resembling the resident was seen near a nearby store. Police, responding to a report of a suspicious person with a hospital bracelet, found the resident disoriented at a nearby intersection and arranged EMS transport to a hospital. Interviews showed that some CNAs lacked elopement training, one CNA was newly assigned to 1:1 care, and leadership acknowledged uncertainty about how long the alarm had been sounding and how the resident exited, supporting the finding of inadequate supervision and failure to prevent elopement.
A resident with traumatic brain injury, moderate cognitive impairment, wheelchair dependence, and documented wandering behaviors eloped from the facility after being able to exit through a door without an active alarm. Despite physician orders and a care plan requiring wander guard checks every shift, MAR/TAR review showed these checks were largely undocumented prior to the incident. Staff notes described frequent redirection needs, room-to-room wandering, and impulsive behavior, yet the resident was still able to leave the building and was later found in the parking lot. The State Agency determined this failure to supervise and to implement ordered wander guard monitoring constituted Immediate Jeopardy under F689 (Quality of Care).
A cognitively impaired resident with dementia and depression, who was usually independent with toileting, became involved in an altercation with a CNA while the CNA was assisting with cleaning a soiled bathroom. The resident became agitated, spit on the CNA, and struck the CNA in the face with a BM-soiled washcloth. In retaliation, the CNA held the resident’s hands and struck the resident in the face with an open hand, later describing the action as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff and law enforcement that she had put her hands on and slapped the resident. Staff assessments noted the resident was visibly upset but without visible injuries, and the resident could not recall the incident due to severe cognitive impairment. Surveyors determined this constituted non-compliance with abuse regulations and cited the facility for failure to ensure freedom from physical abuse.
A resident with severe cognitive impairment, a history of falls, and documented need for a gait belt and walker during transfers was ambulated from the bathroom by a CNA without a gait belt in place. The CNA reported holding the resident’s pants while walking, during which the resident’s feet became twisted and she fell in her room. Facility documentation showed the resident had been assessed as requiring a gait belt, but gait belt use was not included in physician orders or the care plan and was instead communicated via door name tags. The resident sustained a left hip fracture requiring surgical repair and was later readmitted for rehab and strengthening.
A resident with Alzheimer’s disease and hypertension, treated with Benazepril and enrolled in PACE, had multiple significantly elevated BP readings over two consecutive days. Facility policy required prompt physician notification for significant changes in condition, and the care plan directed staff to contact PACE for medical needs. However, there was no documentation in nursing notes that the physician or PACE was notified, and the patient liaison and weekend supervisor reported not being informed. A CNA stated she reported the elevated BP to an RN, but the RN later indicated that if no progress note existed, the notification was not documented, resulting in a failure to notify the physician of the resident’s elevated blood pressures.
A resident with epilepsy, paranoid schizophrenia, and dementia did not receive 11 ordered doses of Lacosamide 100 mg, prescribed as 1.5 tablets PO BID for seizures, because the facility failed to obtain and administer the medication and did not develop a care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR showed repeated omissions, and interviews revealed that although there was a protocol for handling missing medications—requiring nurses to call the pharmacy, notify the MD for alternatives, and check Omnicell—this process was not effectively followed or documented. The DON reported being unaware that there was no prescription for the medication, and the PCP stated she was never notified of the missed doses and that any missing medication should have been communicated to the NP and then to her by direct, immediate means.
Surveyors found that washer filters were heavily soiled with lint and debris on all observed machines, despite manufacturer instructions and a label on the equipment requiring daily cleaning. The Laundry Supervisor stated that laundry staff did not maintain the filters and that maintenance was responsible, while the Maintenance Supervisor reported the filters were typically cleaned three times per week and that no documentation was kept to verify cleaning in accordance with manufacturer guidelines.
A resident with multiple medical conditions and decreased ability to perform ADLs was found with two white tablets in a medication cup on the bedside table, which the resident identified as Imodium saved from a prior medication pass. Facility policy requires staff to remain with residents until oral medications are swallowed and prohibits leaving medications in a room without a self-administration order. Record review confirmed there was no such order for this resident. An LPN verified that medications had been left at the bedside contrary to policy, and the DON stated that nurses are not to leave medications at the bedside and must observe residents swallowing medications.
An LPN pre-poured medications for more than one resident and failed to follow required resident-identification and "five rights" checks, resulting in a resident with dementia and multiple comorbidities receiving another resident’s ordered regimen, including oxycodone 30 mg, multiple antihypertensives, an antiarrhythmic, and gabapentin, none of which were prescribed for her. After receiving the wrong medications mixed in pudding, the resident developed hypotension, bradycardia, somnolence, and hypoxia, with documented very low BP and HR, and was transferred to the hospital where she required IV fluids, naloxone, atropine, and vasopressor support and was diagnosed with drug-induced hypotension, accidental drug overdose, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. Surveyors found that this failure to adhere to the facility’s medication administration policy and to ensure residents were free from significant medication errors constituted non-compliance at F760, rising to Immediate Jeopardy.
The facility failed to report a serious medication error that led to a resident’s hospitalization to the Administrator and State Agency within the required two-hour timeframe. An LPN pre-pulled medications for more than one resident, became distracted, and administered another resident’s medications, including multiple cardiac and pain medications, to a resident with dementia, atrial fibrillation, dysphagia, and depression. The resident subsequently developed hypotension, bradycardia, and decreased respirations and was transferred to the hospital. Although the LPN notified supervisory nursing staff and the NP, the incident was not entered on the reportable incident log, the Administrator was not promptly informed, and the State Agency was not notified, in part because the ADON was unaware of the reporting requirement and the DON was on leave.
Failure to Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had dementia with severe cognitive impairment, a BIMS score of 7/15, generalized muscle weakness, unsteadiness on feet, and abnormal gait and mobility. The admission MDS and care plan identified the resident as at risk for falls and elopement, with documented wandering throughout the facility and a recent elopement. An elopement risk observation completed shortly before the incident documented that the resident did not have safe decision-making capabilities. Nursing staff reported that the resident remained ambulatory with good strength and endurance, had impaired judgment and poor safety awareness, and required close supervision due to ongoing exit-seeking behaviors. On the day of the incident, staff last observed the resident in a safe environment ambulating in the facility between approximately 5:30 PM and 5:40 PM, which was described as baseline behavior. Around this same time frame, the alarm on a dining room/fire exit door near the dietary department sounded. Dietary staff responded, visually checked the area, reported not seeing anyone, re-engaged or disarmed the alarm, and returned to the kitchen. Multiple staff later acknowledged that it was difficult to hear the alarm in the kitchen and that they were unable to determine how long the alarm had been sounding before it was noticed. The facility’s elopement policy required immediate notification of all employees and a prompt, thorough search process when a resident was considered missing, but there is no indication that a facility-wide code or missing resident procedure was initiated at the time the door alarm sounded. Subsequently, between approximately 5:50 PM and 6:05 PM, the resident’s CNA noticed the resident was not in the room to receive a dinner tray and began looking for the resident, prompting a census head count. Staff were unable to locate the resident in the building, and a search was initiated. Around 6:08 PM to 6:39 PM, an employee leaving work by car believed they saw the resident near a nearby Dollar General store and called the facility. A nurse drove to the store but did not find the resident. During this period, the local police were notified by Dollar General about a suspicious person with a hospital bracelet. Police located the resident at a nearby intersection; the police report described the resident as delirious, disoriented, and unable to provide coherent responses. EMS was requested, and the resident was transported to a hospital emergency department. The facility later confirmed that the resident had eloped from the building and was found with a wander guard still in place, and staff, including the administrator and DON, were unable to state exactly how the resident exited the building, though they believed it may have been through the dining room door whose alarm had sounded earlier. Interviews with staff revealed additional gaps related to supervision and elopement procedures. One CNA assigned to 1:1 care for the resident stated it was her first day in that role and could not confirm how long the resident had been on 1:1 care. Another CNA, who had recently completed orientation, reported not receiving any in-service training related to elopements and stated that the survey interview was the first time she heard about the resident’s exit from the building. The LPN on duty reported that the resident had been on 30-minute checks due to wandering, last saw the resident around 5:25 PM–5:30 PM, and assumed the resident was doing usual laps in the facility. The DON and administrator both acknowledged that staff could not determine how long the door alarm had been sounding before it was heard and that staff responded by looking outside, not seeing anything, and shutting off the alarm. These actions and inactions, in the context of a known high-risk, cognitively impaired, exit-seeking resident, led to a successful elopement and formed the basis of the cited deficiency under 42 CFR 483.25 for failure to keep the environment free of accident hazards and provide adequate supervision.
Removal Plan
- Evaluate resident at emergency room; confirm no injuries.
- Initiate and continue 1:1 supervision for the resident.
- Assess each exit door to validate doors are working properly.
- Update the resident’s elopement risk assessment to reflect current status.
- Update the resident’s care plan and resident profile.
- Complete an elopement drill.
- Administrator will notify the charge nurse, Director of Nursing, and Social Service designee that a resident is missing as part of drill procedure.
- Director of Nursing/designee will announce Code [NAME] to signal the elopement drill procedure.
- Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds; complete the entire search process within 30 minutes.
- If search fails to locate resident within allotted time, Administrator/designee will place a mock telephone call to appropriate community agencies, resident's legal representative, and attending physician; staff will provide mock police with physical identifying information.
- Continue the search if resident not located, including having staff search surrounding streets by car for a 2 mile radius.
- When the volunteer resident is located, the charge nurse will complete a head-to-toe assessment.
- Social Services designee will assess the resident for emotional distress.
- Director of Nursing will notify appropriate community agencies, attending physician, and resident's legal representative.
- Facility Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences.
- When missing resident is found, make an announcement: Code [NAME] all clear.
- Update elopement risk assessments for all residents.
- Place residents identified as elopement risk in the elopement binder and update their care plans and profiles.
- Reeducate facility staff on the elopement policy and Abuse, Neglect & Misappropriation policy.
- Provide education to any staff not receiving this education prior to their next scheduled shift.
- Review new admission elopement risk assessments in Clinical Morning Meeting to validate accuracy and interventions if indicated.
- Review quarterly elopement risk assessments to validate accuracy and interventions if indicated.
- Maintenance Director/designee will inspect facility exit doors to validate doors are functioning properly.
- Administrator will round with the Maintenance Director validating doors are functioning properly.
- Hold an Ad Hoc QACPI.
- Notify the Medical Director of the incident and plan.
- Present results of audits in the QAPI Committee meeting for review and recommendations.
Failure to Monitor Wander Guard and Supervise Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent a successful elopement for one resident identified as at risk for wandering and elopement. The resident was admitted with diagnoses including traumatic subdural hemorrhage, muscle weakness, difficulty in walking, and need for assistance with personal care. An admission MDS showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that the resident used a wheelchair and required substantial assistance for most ADLs. The facility’s own policy defined wandering and elopement, required staff training on elopement prevention, and called for interventions and care plan documentation for residents at risk of elopement. Physician orders were in place directing staff to check the resident’s wander guard for effectiveness and function every shift beginning shortly after admission. However, review of the MAR/TAR for the period from admission through the date of elopement showed that this order was not consistently documented as completed. For the period 01/30/26–02/19/26, there was an order to check the wander guard every shift, but it was only signed once on the date of the elopement for the first shift. There was no documentation on the MAR/TAR for January related to checking the wander guard, despite the order being in effect. The resident’s care plan, initiated on admission and revised on 02/19/26, identified behavioral symptoms of wandering and elopement related to impaired cognition and impulsivity, and included an intervention to equip the resident with a wander guard upon admission for 48 hours and to check the device’s proper functioning every shift, but the documented implementation of these checks was lacking. In the days leading up to the elopement, progress notes documented that the resident needed frequent redirection due to wandering in and out of other residents’ rooms, and that staff discussed with the resident’s representative the possibility of obtaining a sitter because of these behaviors. Another note described the resident being found seated on a fall mat after getting out of bed to remove pictures from the wall and pack his bag, indicating ongoing impulsive and wandering behavior. On the night of the elopement, a CNA reported that the resident had been described as hard to redirect and constantly pacing the unit in his wheelchair. Later that night, the resident was found wandering in the parking lot and brought back inside by a CNA; the nurse documented that the door alarm was not going off at the time the resident was found outside. The resident’s representative later stated that he had been informed that the front door was not working properly and that the resident had a wander guard device that should have locked the door when he left, but the door did not function correctly, allowing the resident to exit the building. Based on these findings, surveyors determined that the facility failed to provide adequate supervision and accident prevention, resulting in a successful elopement and an Immediate Jeopardy determination at F689. The State Agency determined that the facility’s non-compliance with federal health and safety regulations caused or was likely to cause serious injury, harm, impairment, or death, and identified the Immediate Jeopardy as related to 42 CFR 483.25, Quality of Care. The Immediate Jeopardy was determined to have existed as of the date of the elopement. The survey findings emphasized the lack of documented adherence to physician orders and care plan interventions for checking the wander guard device, the presence of documented wandering and impulsive behaviors, and the fact that the resident was able to leave the building without triggering a door alarm. These combined actions and inactions led to the conclusion that the facility did not ensure the environment was free from accident hazards and did not provide adequate supervision to prevent the resident’s elopement.
Removal Plan
- Resident was immediately located and safely returned to the facility.
- Full nursing assessment completed by licensed nurse; no injuries noted.
- Physician/Medical Director and responsible party notified by administrator.
- Resident placed on increased monitoring immediately.
- Wandering/elopement risk reassessed.
- Care plan updated to include enhanced interventions.
- Wander guard applied and verified functioning.
- Staff education initiated by administrator.
- Incident reported per facility policy and state requirements.
- Facility conducted a 100% audit of all residents for elopement risk.
- Verified wander guard placement and function for all residents.
- Verified accuracy of assessments and care plans for all residents.
- Updated care plans to include individualized interventions such as secured unit placement/discharge plan and structured activities to reduce wandering.
- Conducted environmental safety checks.
- All exit doors secured and alarmed and verified by maintenance department weekly.
- Wander guard system tested by maintenance department weekly with a log.
- All staff education completed by DON/Administrator on policy/protocol for wandering and elopement and immediate response procedures if a resident is missing.
- Results reviewed in QWAPI meetings monthly for 3 months, with corrective actions implemented as needed.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident from physical abuse by a CNA. The facility’s abuse policy defines physical abuse as including hitting, slapping, and controlling behavior through corporal punishment. The resident involved was admitted with major depressive disorder and dementia with agitation, and a recent MDS showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident was generally independent with toileting and transfers. On the day of the incident, the resident was on a locked dementia unit and had experienced bowel incontinence, leaving the bathroom soiled. A CNA entered the resident’s room to assist with cleaning the bathroom. During this interaction, the resident became agitated and combative, reportedly spitting on the CNA and striking the CNA in the face with a wet washcloth containing bowel movement. The CNA later reported that she responded by holding the resident’s hands above her head and then making contact with the resident’s face with an open hand, described as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff, including the charge nurse, DON, Administrator, and Social Services, that she had put her hands on the resident and struck the resident in the face with an open hand in retaliation for the resident’s actions. A police report documented that the CNA admitted to assaulting the resident with an open-hand slap during a physical altercation. Staff who assessed the resident after the incident noted that the resident appeared visibly upset but had no visible injuries, and the resident was unable to recall the specific events due to severe cognitive impairment. The State Agency determined that the facility’s non-compliance with abuse regulations caused or was likely to cause serious harm and cited the facility under 42 CFR 483.12 for failure to ensure the resident was free from physical abuse.
Removal Plan
- Removed CNA3 from the resident care area after the incident.
- Interviewed CNA3 regarding the incident.
- Terminated CNA3 by the Administrator and DON.
- Notified law enforcement of the incident.
- Submitted a report to the Regional Ombudsman.
- Completed a nursing assessment and body audit of R1; no injuries found.
- Notified R1's family/responsible party of the incident.
- Monitored residents for psychosocial distress or changes by nursing staff and Social Services.
- Provided 1:1 re-education for staff working in skilled nursing on abuse and appropriate response/intervention and workplace fatigue.
- Conducted an investigation and determined there was no physical evidence of abuse.
- Social worker interviewed all residents on Unit 3 regarding abuse, whether any abuse had been witnessed/experienced, and whether residents felt safe.
- Social worker interviewed residents on other skilled units regarding abuse and whether residents felt safe.
- Arranged for MD and PA to evaluate R1; MD issued new medication orders and PA checked on the resident.
- Obtained family consent for a psychiatric evaluation.
- Social worker contacted the family and obtained updates; family visited and reported no changes in mood/behavior/psychosocial status.
- Social worker checked in on R1 and monitored for changes.
- Initiated in-house education for all staff working in Skilled Nursing on types/definitions of abuse, dementia with abuse prevention, de-escalation of behaviors, and how to appropriately avoid these situations.
- Re-educated staff on who the Abuse Coordinator is and how to notify the Abuse Coordinator of concerns.
- Reviewed the abuse policy with staff.
- Obtained statements from all staff who work in Skilled Nursing.
- Continued education ongoing.
- Nursing management (DON, ADON, Unit Managers) to conduct rounding and audits for signs of abuse.
- Held QAPI and updated it regarding this issue.
Failure to Use Required Gait Belt During Ambulation Resulting in Hip Fracture
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards and received adequate supervision during ambulation, resulting in a fall and left hip fracture. The facility’s Fall Management Program policy included staff education and interventions to prevent unsafe transfers and ambulation. The resident had severe cognitive impairment, as evidenced by a BIMS score of 3/15, and used a walker and wheelchair. A Safe Resident Handling Data Collection form documented that a gait belt and walker were required for transfers with staff and that the resident continued to require use of a gait belt. The resident’s care plan included assistance with transfers and ambulation and provision of adaptive equipment, but there was no physician order for a gait belt, and gait belt use was not listed on the care plan. Instead, the Administrator stated that transfer methods, including gait belt use, were communicated via name tags on residents’ doors and that the resident had a history of tripping over her own feet and falling. On the day of the incident, the resident was being assisted by a CNA from the bathroom when the resident’s feet became twisted and she fell to the floor. The CNA reported she was holding the resident’s pants while walking her from the bathroom and acknowledged that the fall was her fault. Documentation indicated the resident fell in her room while being transferred/ambulated from the bathroom with the CNA present, wearing shoes at the time. The Administrator confirmed that the resident had been assessed for gait belt use and that the resident did not have a gait belt on when she fell. The Administrator stated that, in situations where a resident is already in motion without proper equipment, staff should hold the resident and call for help rather than continue ambulation. The resident sustained a subcapital femoral neck fracture of the left hip, required surgical repair at a hospital, and was later readmitted to the facility for rehabilitation and strengthening, with documentation noting she had been confined to a wheelchair prior to the fall and was unlikely to progress beyond her previous level of activity.
Failure to Notify Physician of Resident’s Elevated Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significantly elevated blood pressures as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised February 2021, states that the nurse will promptly notify the attending or on-call physician when there is a significant change in the resident’s physical condition, defined as a major decline or improvement that will not normally resolve without intervention. The resident was admitted with diagnoses including Alzheimer’s disease, essential hypertension, and hypothyroidism, and had an active order for Benazepril 5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure (SBP) was less than 110. The admission MDS showed the resident was unable to complete the BIMS interview and had an active diagnosis of hypertension. Blood pressure records showed multiple elevated readings, including 172/102 and 172/101 on one day and 171/119 on the following day. Review of the nurse’s notes revealed no documentation that the physician or PACE program was notified of these elevated blood pressures. The care plan indicated the resident was a PACE participant and directed staff to contact PACE for any medical needs. During interviews, the UM stated all medication orders came from PACE, and the DON acknowledged that 171/119 was an elevated blood pressure and that a call should have been made to the on-call PACE medical director, with family also to be notified of the change in condition. The patient liaison and weekend supervisor both reported not being informed of the elevated blood pressures, and CNA staff reported notifying an RN of the elevated readings but was unsure what occurred afterward. The RN stated she did not recall the patient but indicated that if there was no progress note, the notification would not have been documented anywhere else.
Failure to Obtain and Administer Ordered Seizure Medication
Penalty
Summary
The facility failed to obtain and administer Lacosamide, an ordered seizure medication, for one resident, resulting in 11 missed doses over the period from 1/7 to 1/13. The resident was admitted with diagnoses including epilepsy, paranoid schizophrenia, and dementia. Review of the care plan showed no care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR for 1/7/26 through 1/14/26 showed that the resident did not receive Lacosamide 100 mg, ordered as 1.5 tablets by mouth twice daily for seizures, for a total of 11 missed doses. The facility’s policy on Adverse Consequences and Medication Errors defined a medication error to include omissions when a drug is ordered but not administered. During interviews, an LPN stated that if a progress note about Lacosamide not being given was scratched out, it meant the medication was administered, and that when waiting for a medication, the nurse keeps a running list and calls the pharmacy for status updates. The Staff Development Coordinator reported that the protocol for missing medications requires nurses to call the pharmacy and document the call, notify the MD for alternatives, and check the Omnicell if the medication is not a narcotic. The DON stated that on admission, floor nurses should send all prescriptions to the pharmacy and, if a prescription is missing, contact onsite/on-call providers to obtain one so the pharmacy can send the medication stat, and reported being unaware that there was no prescription for Lacosamide. The resident’s PCP stated she had no memory of being notified about any missed Lacosamide doses and explained that the NP should be notified first and work with the pharmacy, and if issues persist, the PCP should be contacted; she also stated that missing medication should be communicated immediately by direct means, not by a note left in a book.
Failure to Maintain Washer Filters per Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the maintenance of laundry equipment. Review of the Alliance Laundry Systems washer manufacturer guidelines showed that, as part of end-of-day maintenance, the AC invert drive filter was to be cleaned by removing the external plastic cover, taking out the foam filter, and washing it with warm water and allowing it to air dry, or by vacuuming the filter. During an observation of the laundry area, the filter located on the front of the washing machine was found to be heavily soiled with lint and debris, despite a metal manufacturer label directly beneath the filter stating, "Clean Daily." Three of three washing machines observed had this issue. In an interview conducted at the time of the observation, the Laundry Supervisor acknowledged the condition of the filter and stated that laundry personnel did not maintain the filter, indicating that maintenance staff were responsible for cleaning it. In a subsequent interview, the Maintenance Supervisor reported that maintenance staff usually cleaned the filter about three times a week on Monday, Wednesday, and Friday, rather than daily as directed by the manufacturer. The Maintenance Supervisor also stated there was no log or record maintained to verify that the filter was cleaned as required.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when medications were left at the bedside for one resident. The facility’s “Oral Medication Administration Procedure” policy states that staff must administer oral medications in an organized and safe manner, remain with the resident while the medication is swallowed, and never leave medication in a resident’s room without an order for self-administration. Review of the resident’s orders showed there was no order for self-administration of medication. The resident involved had diagnoses including post hemorrhagic anemia, gastrointestinal hemorrhage, irritable bowel syndrome, and osteoarthritis, and had a BIMS score of 15/15, indicating no cognitive impairment. The baseline care plan documented decreased ability to perform ADLs/self-care related to debility/generalized weakness. During observation, two white tablets were found in a medication cup on the resident’s bedside table. An LPN confirmed the medications should not have been left in the room and that the resident did not have an order to self-administer. The resident stated that a nurse had brought the medications the previous night and that she was saving them to use when needed, identifying them as Imodium. The DON stated that nurses are not to leave medications at the bedside and should remain with the resident to ensure medications are swallowed safely, and that anyone could take medications left at the bedside.
Significant Medication Error When Wrong Resident Received Another Resident’s Medications
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.
Removal Plan
- The Administrator notified the Medical Director of the Immediate Jeopardy.
- R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
- R2 was sent to the emergency department for a higher level of care.
- The Assistant Director of Nursing began the investigation into the medication error.
- The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
- The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
- The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
- The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
- The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
- The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
- The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
- The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
- The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
- Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
- The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.
Failure to Report Serious Medication Error Resulting in Resident Hospitalization
Penalty
Summary
The facility failed to timely report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within two hours, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, last revised in September 2022, states that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the Administrator and appropriate authorities, defining "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury. Despite this, the medication error involving Resident 2, which led to hospitalization, was not entered on the facility’s reportable incident log and was not reported to the State Agency or Administrator as required. Resident 2 was admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. On the morning of 12/04/25, LPN1 pre-pulled medications for more than one resident at a time and prepared medications for Resident 2 and Resident 3. When Resident 3 requested pain medication, LPN1 retrieved oxycodone for Resident 3 but then became distracted and administered Resident 3’s medications to Resident 2 instead. Witness statements from the Unit Manager and ADON documented that Resident 2 received multiple medications not prescribed for them, including oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide, gabapentin 600 mg, and metoprolol 50 mg. Progress notes show that Resident 2’s blood pressure remained low despite ordered midodrine and fluids, with documented hypotension, bradycardia, and decreased respirations, and the resident was ultimately transferred to the hospital for further evaluation. Following the error, LPN1 reported the incident to her supervisor, and the ADON and NP were notified; however, the Administrator and State Agency were not notified as required by policy. The DON, who was on maternity leave at the time, later stated that the incident should have been reported to the State Agency but confirmed that no report was submitted and that the ADON was unaware the incident needed to be reported. The ADON stated she was unsure if the Administrator had been notified and acknowledged she did not know she was required to report the incident to the State Agency. The Facility Administrator reported that he only became aware of the medication error recently, after speaking with another resident, and confirmed that no report had been sent to the State Agency and that he had not been informed of the incident when it occurred.
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