Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Oaks Post Acute during CMS and state inspections, most recent first.
Food storage and handling were not maintained according to policy in the kitchen, a unit nourishment room, and a medication room. A kitchen staff member was observed without a hairnet, several dry-storage items were unlabeled or expired, two sandwiches were left at room temperature in a medication room, and a resident’s personal food item in a nourishment room refrigerator lacked an item description and use-by date. The nourishment room refrigerator did not seal properly and had no thermometer, and staff stated it was out of order.
The facility failed to maintain a clean, safe, and homelike environment when common-area equipment, including a snack cart and a Hoyer lift, was observed with dried debris and dust despite policies requiring regular cleaning. One resident’s room had a persistent strong urine and feces odor, with used briefs, a soiled gown, and trash left on the closet floor for several days, and the same resident’s wheelchair had a wheel held on for months with zip ties, string, and cloth without a maintenance report. Another resident’s overhead light cover had fallen and remained off for weeks, leaning against the wall, while a different resident’s bathroom repeatedly had an offensive odor and a wash basin filled with dirty towels and water on the shower floor, even as staff entered the room. Interviews showed that housekeeping lacked clear schedules for cleaning equipment, maintenance had no set cleaning schedule and was unaware of specific room issues, and staff misunderstood or inconsistently used the QR code work-order system, despite leadership expectations that all staff help maintain cleanliness and report problems.
Improper Storage and Labeling of Medications and Biologicals: Surveyors found multiple medication storage issues in several medication rooms and a medication cart, including an opened Aplisol vial that was not dated, an expired sterile water item, a Breztri inhaler that exceeded the manufacturer’s opening timeframe, and two opened expired OTC medications. Staff confirmed the findings, and the DON stated that expired medications should be removed from active storage.
Failure to Provide Quarterly Personal Fund Statements: A resident with dementia and severe cognitive impairment had a personal funds account, but the RP reported not receiving quarterly statements since new management took over. The BM said statements were sent only as a general list note and no individual proof was kept, while the ADM was unsure of the exact process. The facility policy required individual accounting records to be made available through quarterly statements and upon request.
A resident with dementia had a documented yellowish vaginal discharge, but the concern was not reported to the physician/NP as required by facility protocol. In a separate finding, an empty vial labeled for another resident’s PRN nitroglycerin was found on the med cart with no medication available, and an LPN could not locate the stock; the DON stated meds are to be ordered in time to prevent residents from running out.
A resident who was dependent for all transfers fell during a Hoyer lift transfer when staff used the wrong sling/pad and the lift gave way as the resident was being moved from bed to chair. The resident, who had multiple chronic conditions including hemiplegia/hemiparesis after CVA, said she was lifted too high and fell out on her left side, later going to the hospital. Staff reported the usual front-crossing pad for this resident was not available, and the RN stated the pad used did not have the crisscross leg support needed for the transfer.
A resident with COPD, anxiety disorder, and dementia had nebulizer equipment left unbagged and stored beside the bed next to shoes, with dated tubing not documented and a clear liquid left in the medication chamber. The O2 concentrator was also found set above the ordered rate, and an LPN confirmed the incorrect setting before adjusting it to the prescribed LPM. The DON stated the mask should be covered when not in use and the oxygen rate checked every shift.
Failure to provide hand hygiene before meals and prevent cross-contamination by housekeeping staff. Staff brought residents to the dining room without offering hand sanitizer, and one resident ate with his hands. A housekeeper was observed leaving the unit and re-entering the hallway with a mop cart while still wearing gloves. CNA and housekeeping interviews confirmed inconsistent hand hygiene practices and lack of formal infection control training.
A resident, who was cognitively intact and had multiple medical conditions, allowed a CNA to borrow her cellphone, after which unauthorized financial transactions and online purchases were made using her accounts. The CNA had access to the phone for an extended period and was linked to the fraudulent activity through bank records and text alerts. The incident was reported and substantiated as misappropriation of resident property.
A resident with multiple diagnoses and a history of falls had inconsistent and incomplete fall risk assessments, with missing documentation of health conditions and prescribed medications. Despite facility policy requiring thorough assessment and documentation, several assessments failed to accurately reflect the resident's risk factors, and the DON was unable to explain the omissions.
Surveyors found multiple medications and nutritional supplements, including creams, patches, solutions, and drinks, stored directly on the floor rather than in designated secure storage. The DON and CSM confirmed that supplies should not be stored on the floor and that a recent delivery was left unattended due to the CSM's absence over the weekend.
A resident with a Full Code Advanced Directive was found unresponsive, but CPR was not initiated as required by facility policy. The resident, who had severe cognitive impairment and multiple diagnoses, was mistakenly identified as DNR by staff, leading to a failure to provide necessary life-saving measures. Interviews revealed miscommunication among staff regarding the resident's code status, resulting in a deficiency identified by surveyors.
The facility failed to store biologicals appropriately in three medication treatment carts, with expired and opened items found during observations. Interviews with staff revealed inconsistent checking of expiration dates and proper storage, despite facility policy requiring locked compartments and proper conditions. The DON acknowledged that both wound and floor nurses should check for expirations.
The facility failed to keep the kitchen's ice machine clean and sanitized, as a black mold-like substance was observed around the ice dispenser. The Kitchen Manager confirmed the issue and stated that the machine should be cleaned daily, but no cleaning logs were available. Additionally, the facility lacked a policy for ice machine maintenance.
A facility failed to develop a comprehensive care plan for a resident, omitting Advance Directives despite the resident's severe cognitive impairment and multiple diagnoses. Interviews with staff confirmed the absence of necessary interventions in the resident's electronic medical record, highlighting a deviation from the facility's policy.
A facility failed to include Advanced Directives in a resident's care plan, despite the resident's severe cognitive impairment. The facility's policy mandates a comprehensive, person-centered care plan developed by the interdisciplinary team, but interviews with staff confirmed the absence of such interventions in the resident's EMR.
A resident dependent on staff for ADLs did not receive necessary hygiene services, as no showers were documented from June to November 2024. Observations showed the resident unshaven and with crusty eyes, and interviews confirmed the resident was not offered showers despite being scheduled for them. Staff assumed bed baths were provided by the previous shift, leading to a failure in maintaining personal hygiene.
A resident with mobility issues and a history of falls did not have a bed pad alarm in place as required by their care plan. Despite the care plan's inclusion of a bed pad alarm for fall prevention, observations showed it was missing, and staff interviews revealed confusion about its status. The resident fell while reaching for the call light, highlighting a deficiency in the facility's fall prevention measures.
A resident with multiple health conditions, including seizures and paraplegia, was not provided adequate hydration as per facility policy. Observations and interviews revealed the resident was not offered fluids between meals, and documentation showed insufficient fluid intake on certain dates. The facility's policy requires regular hydration assessments and documentation, which were not adhered to in this case.
A resident's responsible party was not timely informed of an unstageable wound on the resident's left hip, despite facility policy requiring notification of significant changes. The wound was documented as new, but the responsible party only learned of it during a visit, confirmed by interviews with facility staff.
A facility failed to document a resident's grievance regarding care concerns, despite the facility's policy allowing residents and their representatives to voice grievances without fear of reprisal. The resident's personal representative reported issues such as odors, a fall, a hip wound, and the state of the resident's room to the head of nursing, social worker, and wound nurse, who assured that the issues would be addressed. However, the concerns were not formally documented in the grievance log, indicating a deficiency in the facility's grievance handling process.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards in the kitchen, a unit nourishment room, and a medication room. Facility policy required food to be received and stored using safe food handling practices, refrigerated foods to be kept below 41F, food on nursing units to be labeled with the resident’s name, item, and use-by date, and food service staff to wear hair restraints while preparing and serving food. During observation in the kitchen, a kitchen staff member was in the kitchen without a hairnet and stated they had returned from a break through the back door, where hairnets were not available. In the dry storage room, surveyors observed a plastic grocery bag containing two packs of hazelnut coffee with an expiration date of December 2025, a box of thickened liquids that was not dated when received, and an opened bag of bread crumbs in a plastic storage container with a use-by date of 10/19/25. The dietary director stated that all food items should be labeled and dated when received and when to use by. In the Riverside unit medication room, two pimento cheese sandwiches were observed wrapped in plastic wrap on a snack tray at room temperature, and an LPN stated they should have been refrigerated. In the nourishment room for Riverside and another unit, a personal food item for R33 was found in the freezer area of the refrigerator in a container labeled only with the resident’s last name, with no item description or use-by date. The refrigerator door did not adequately seal and there was no thermometer present; multiple food items were inside. An LPN later stated the refrigerator was out of order because it did not seal properly, and nursing staff were responsible for ensuring nourishment room refrigerators were maintained and food items were labeled, dated, and discarded in a timely manner.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on multiple units and in several resident rooms. Facility policies required regular cleaning and disinfecting of housekeeping and environmental surfaces, yet surveyors observed a white PVC snack cart near the nursing station on the Riverside unit with dried brown liquid, crumbs, and dust on the bottom shelf, and a Hoyer lift in a hallway alcove with dried debris and dust on its base and in crevices. The Lead Housekeeper acknowledged the cart was an old snack cart that should not be there and should be cleaned, and stated there was no clear knowledge of how often equipment was power washed. The Maintenance Director reported there was no set schedule for cleaning equipment such as Hoyer lifts and that they only tried to do it quarterly. In one resident room, surveyors repeatedly noted a strong odor of urine and feces and found four used briefs, a dirty hospital gown, and an empty ginger ale can on the floor of the resident’s closet over multiple days without change. The resident reported that these items had been on the closet floor for four days. The same resident also reported that the left wheel of her wheelchair had been held in place with zip ties, string, and cloth for months, and observations confirmed the wheel remained secured in this makeshift manner on several occasions. The Maintenance Director stated he was not aware of any maintenance issues in that room and had not been informed of the loose wheel. In another resident room, the overhead light cover had fallen off and was observed leaning against the wall on multiple days, with the resident stating that the cover had come off a couple of weeks earlier and expressing relief that it had not fallen over her bed. The Maintenance Director confirmed there was no work order in the QR code system for that room and that he was unaware of the issue. Additionally, a different resident’s bathroom was repeatedly observed to have an offensive odor and a plastic wash basin filled with dirty towels and water sitting on the shower stall floor over several days, despite various housekeeping staff, CNAs, and nurses entering the room. An LPN confirmed the condition of the bathroom and stated that the resident sometimes threw items there and that housekeeping would be notified. Interviews with the DON and Administrator indicated an expectation that all staff help keep rooms clean and that anyone with a phone could submit maintenance work orders via QR codes, but staff appeared to misunderstand or not consistently use this process.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in 2 of 3 medication rooms and 1 of 6 medication carts. The facility policy titled Medication Labeling and Storage states that discontinued, outdated, or deteriorated medications are to be handled through the dispensing pharmacy and that multi-dose vials that have been opened or accessed are to be dated. Manufacturer labeling for Aplisol also stated that once entered, the vial should be discarded after 30 days, and that improper storage and handling may result in loss of potency and inaccurate test results. During observations, surveyors found an opened vial of Aplisol in the A Wing medication room refrigerator that was not dated as to the opened date. In the Riverside D Wing medication room, surveyors found one RCI Prefilled Humidifier Aqua Pak sterile water item that had expired on 8/20/25. On the Riverside D Wing medication cart, surveyors found a Breztri Aerosphere inhaler dated by the facility as opened on 08/10/25, while the manufacturer labeling stated it should be discarded within 3 months of opening. In the Palmetto C Wing medication room, surveyors found an opened bottle of Stool Softener expired in 01/2025 and an opened bottle of Levocetirizine 5 mg Allergy Relief expired in 04/2024. Staff interviews confirmed these findings, and the DON stated that expired medications should be removed from active storage.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly account statements for one resident’s personal funds account. The facility policy titled Accounting and Records of Personal Funds states that individual accounting records are made available to the resident through quarterly statements and upon request. Review of the resident’s face sheet showed diagnoses including type 2 diabetes, dementia, major depressive disorder, epilepsy, and high blood pressure. The resident’s quarterly MDS assessment showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. During interview, the resident’s responsible party stated she received $30 a month and had not received a statement since new management took over, although she had previously received one every quarter. The Business Manager stated she had not sent a statement because no money was put into the resident’s account, and said quarterly statements were sent as a general statement with a note at the bottom of the list indicating they were sent out. She also stated she did not make notations on individual accounts or keep records such as copies of envelopes to show the statements were sent. The Administrator stated each account was different, believed statements went out quarterly, and said they would need to ask the Business Manager to be sure.
Failure to Report Clinical Concern and Maintain Ordered Medication Stock
Penalty
Summary
The facility failed to notify a physician or NP of a clinical concern related to a resident with unspecified dementia. R23 was admitted with diagnoses including unspecified dementia, and during an initial tour on 01/11/26, the resident pointed to an area of concern on her body. A progress note dated 01/09/26 documented that the resident had a yellowish vaginal discharge with no complaint of itching or burning. When the note was reviewed, an LPN stated the finding should have been reported to the physician or NP via the QR code On Site, and the NP later stated the concern should have been reported to him and had not been reported. The DON stated nurses were expected to notify the physician/NP of any concern about a resident. The facility also failed to maintain stock of an ordered medication for another resident. R6 was admitted with diagnoses including cardiac heart failure and dementia. During inspection of Medication Cart #2 on the Riverside (D Wing), surveyors found an empty dispensing vial labeled for R6 containing Nitroglycerin 1 sublingual every 5 minutes x 2 as needed for chest pain, with no bottle of nitroglycerin in the vial or medication cart. An LPN searched the cart and was unable to locate the nitroglycerin vial. The DON stated medications are to be ordered according to the pharmacy contract in time to prevent residents from running out of a prescribed medication.
Improper Hoyer Lift Sling Use During Resident Transfer
Penalty
Summary
The facility failed to ensure proper use of a Hoyer lift for one resident who was dependent with all transfers and had diagnoses including type 2 diabetes mellitus, muscle spasm, hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side, and systemic lupus erythematosus. The resident’s care plan directed staff to ensure the proper lift pad was used when transferring the resident. The facility policy required two nursing assistants for mechanical lift transfers, proper sling selection based on the resident and task, and verification that the sling and machine were compatible and properly attached before lifting. A facility incident report documented that the resident fell during a Hoyer lift transfer and had no injuries observed at the time of the incident. The resident stated that staff lifted her too high and she fell out on her left side, and she later went to the hospital. A CNA stated that while transferring the resident from bed to chair, the lift gave way when another CNA pulled the lift from under the bed, causing the resident’s weight to shift and the resident to fall out of the sling. The CNA also stated that the lift pad normally used for this resident, which crosses over in the front, was not available and that she did not remember what pad was used. An RN stated that the resident was transferred using the wrong lift pad and that the pad used was straight with no crisscrosses for the legs, rather than the pad that crosses over in the front. The RN further stated the resident was adamant about getting up to meet a friend. The DON stated the pad used was a new type of lift pad that does not cross over in the front and said this was new technology. Therapy staff stated there were two sizes of lift pads and that nursing communication was used to tell CNAs what type and size of sling to use, while an LPN stated the size of the lift pad was not located on the care plan, physician orders, or nursing assistant assignment sheets.
Improper Storage and Oxygen Setting for Nebulizer Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident with COPD, anxiety disorder, and dementia. Review of the facility's Oxygen Administration policy showed guidance for safe oxygen administration, but it did not include documentation regarding the maintenance and storage of respiratory equipment such as a nebulizer machine, oxygen mask, or medication chamber. The Regional Nurse Consultant stated there was no separate policy for cleaning and storage of a nebulizer machine and that it should be included in the oxygen policy. Observation and record review of the resident's room showed the oxygen concentrator set above the ordered rate of 2 LPM, with tubing that was not dated. The resident's nebulizer was left in a chair beside the bed next to the resident's tennis shoes, the nebulizer tubing was not dated, the oxygen mask was propped against the machine and attached to the medication chamber and tubing, and neither the mask nor the medication chamber was bagged. A clear liquid was noted in the medication chamber. An LPN later stated she had not bagged the nebulizer mask or washed out the medication chamber and verified that the oxygen was set at 3.0 LPM instead of the ordered 2 LPM before adjusting it to the correct rate.
Failure to Provide Hand Hygiene and Prevent Cross-Contamination
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help decrease the risk of infections by not offering residents hand hygiene before dining in the 400 Riverside Unit. During an observation on 01/11/26 at 12:55 PM, staff began bringing residents to the dining room and did not offer any hand sanitizer before meals were served. One resident was observed eating a hamburger patty with his hands. During an interview, CNA1 stated that residents are supposed to have their hands sanitized before eating, but she had not seen sanitizer on the meal tray container lately and said it used to be provided there. The facility also failed to prevent potential cross-contamination by housekeeping staff. During an observation on 01/11/26 at 12:20 PM, a housekeeper left the 400 Riverside Unit wearing blue disposable gloves, entered a utility room in the main hallway outside the unit's locked doors, and then re-entered the hallway with a mobile mop/cleaning unit while still wearing the same gloves. The housekeeper stated she had not been trained on infection control measures. The Lead Housekeeper stated staff should not wear gloves when leaving the unit and said she teaches new employees infection control practices, but there is no online or written training.
CNA Misappropriation of Resident Property via Cellphone Access
Penalty
Summary
A certified nursing assistant (CNA) was found to have misappropriated a resident's property after being allowed to borrow the resident's cellphone. The resident, who was cognitively intact and had a history of diabetes, hypertension, malnutrition, and muscle spasm, reported that the CNA borrowed her phone for approximately 30 minutes under the pretense of locating her own misplaced phone. Shortly after, the resident received notifications from her bank regarding unauthorized attempts to transfer funds via Cash App and to make online purchases. The resident's bank confirmed that two transactions were attempted for $600 and $100, both of which were declined, while a $10 transaction and a $21.05 online purchase were completed but later credited back due to fraud. The resident denied authorizing any of these transactions. Facility records and interviews confirmed that the CNA had access to the resident's phone during the time the fraudulent activities occurred. The CNA initially denied any wrongdoing but later stated that a $10 transfer may have been an accident. The resident's representative expressed disappointment and frustration, and it was unclear if the facility had notified him about the incident. The facility's policies require immediate reporting and investigation of suspected misappropriation, and the incident was reported to law enforcement, though the resident declined to press charges. The investigation revealed that the CNA took the resident's phone outside the room and used it for purposes beyond what was permitted. Text messages and bank statements reviewed by staff and law enforcement corroborated the resident's account of unauthorized transactions. The CNA was suspended during the investigation, and the incident was substantiated as misappropriation of resident property.
Inaccurate Fall Risk Assessment Documentation
Penalty
Summary
The facility failed to accurately document fall risk assessments for one resident, resulting in incomplete or inconsistent recording of risk factors and medications. According to facility policy, nurses are required to assess and document all current medications and active diagnoses, and staff must review and document each resident's risk factors for falling. However, review of the resident's records showed discrepancies in the fall risk assessments, including missing or inaccurate documentation of health conditions, risk factors, and medications, despite the resident having multiple diagnoses such as Alzheimer's Disease, dementia, hypertension, and major depressive disorder, and being prescribed medications including aspirin, gabapentin, melatonin, and amlodipine. The resident's Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment and assistance needs, as well as a history of falls. Despite this, several fall risk assessments failed to accurately reflect the resident's medication use and health conditions, with some assessments indicating no risk factors or medications when they were present. The care plan did note the resident's risk for falls and use of antiplatelet medication, but the fall risk assessments did not consistently align with this information. The DON confirmed that floor nurses are responsible for completing these assessments but was unsure why the required information was omitted.
Improper Storage of Biologicals and Supplements
Penalty
Summary
The facility failed to ensure that biologicals and supplements were stored in accordance with its own policy and accepted professional standards. During a tour of Riverside Hall, surveyors observed multiple packages and boxes of medications and nutritional supplements, including hydrocortisone cream, lidocaine patches, povidone iodine solution, gauze rolls, and various nutritional drinks, stored directly on the floor. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, specifically in locked compartments and under proper environmental controls, with access limited to authorized personnel. Interviews with the Director of Nursing (DON) and the Central Supply Manager (CSM) confirmed that the observed supplies were not stored according to policy. The CSM acknowledged that supplies are supposed to be stored in designated areas, not on the floor, and explained that she is responsible for putting away supplies when delivered. She further stated that a recent delivery occurred on a Friday, but she does not work weekends, resulting in the supplies being left on the floor until she returned.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) to a resident, identified as R163, who had an Advanced Directive indicating Full Code status. The resident was found unresponsive, and despite the directive, CPR was not initiated. The incident was reported to have occurred at approximately 4:10 PM, which was also the time of death as recorded by the County Coroner's Office. The facility's policy mandates that CPR should be initiated immediately for residents with Full Code status, but this protocol was not followed. R163 was admitted to the facility with multiple diagnoses, including dementia with psychotic disturbance and muscle weakness. The resident had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Despite these conditions, the resident's Advanced Directive clearly stated a desire for CPR in the event of cardiac arrest. However, the facility's records showed a lack of documentation regarding the initiation of CPR or any vital signs taken at the time of the resident's death. Interviews with facility staff, including Licensed Practical Nurses (LPNs), the Nurse Practitioner (NP), and the Director of Nursing (DON), revealed confusion and miscommunication regarding the resident's code status. The NP was informed by nursing staff that the resident was a Do Not Resuscitate (DNR), which contradicted the resident's documented Full Code status. The Medical Doctor confirmed that the resident was never switched to a DNR and emphasized that the family wanted all possible measures taken. This miscommunication and failure to adhere to the resident's Advanced Directive led to the deficiency identified by the surveyors.
Removal Plan
- Audit completed by the Social Services Director on all residents to ensure that all advanced directive paperwork is present and correct Physician's Order is in the Electronic Medical Record and Care Plan is correct.
- Education initiated for all licensed staff by the DON and designees to include what to do if you find someone unresponsive and initiate CPR.
- All newly hired nurses, agency nurses, or facility staff not reached by phone will receive the education prior to their next scheduled shift at the facility.
- Mock Code Blue drills to be conducted by the DON/designee and alternate shifts to ensure all shifts receive training.
- Audit/review of all deaths in the facility will be reviewed by the Nursing Administration team to ensure that CPR is initiated when needed for full code status and documentation is complete.
- SSD will do a random audit of five residents to ensure that code status paperwork is correct and order matches and correlating Care Plan is in place.
- Audits will be for four weeks then for two months then random thereafter.
- Results will be reported to the Quality Assurance committee to determine the need for further monitoring.
Improper Storage of Biologicals in Medication Treatment Carts
Penalty
Summary
The facility failed to ensure that biologicals were stored appropriately in three of their medication treatment carts. During observations, it was found that several items, including Gentell rolled gauze bandage and Silvercel Non-adherent antimicrobial Alginate Dressing, were either expired or opened. The facility's policy requires that all medications and biologicals be stored in locked compartments under proper conditions, and that expired or deteriorated items be returned or destroyed as per the dispensing pharmacy's instructions. However, these protocols were not followed, as evidenced by the presence of expired and opened items in the treatment carts. Interviews with staff, including LPNs and the Director of Nursing, revealed that there was a lack of consistent checking of expiration dates and proper storage of biologicals. The wound nurse and unit managers were responsible for checking expiration dates, but it was noted that all nurses were responsible for changing dressings. Despite this, expired and opened items were found in the treatment carts, indicating a lapse in adherence to the facility's medication labeling and storage policy. The Director of Nursing acknowledged that both the wound nurse and floor nurse should be checking the treatment carts for expirations, highlighting a gap in the implementation of the facility's procedures.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and sanitation of the ice machine in the kitchen. During an initial tour, a black mold-like substance was observed around the ice dispenser of the ice machine. The Kitchen Manager confirmed the presence of the mold-like substance and stated that the ice machine is expected to be cleaned daily at the end of the day. However, there were no cleaning logs available for the ice machine, indicating a lack of documentation for its maintenance. Additionally, the facility did not have a policy regarding the cleaning and sanitization of the ice machine, as confirmed by the Administrator.
Failure to Develop Care Plan for Advance Directives
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically regarding Advance Directives. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, including measurable objectives and timetables to meet the resident's needs. However, upon review, it was found that the care plan for a resident admitted with multiple diagnoses, including dementia with psychotic disturbance and severe cognitive impairment, did not include any planning for Advance Directives. Interviews with facility staff, including an LPN and the Administrator and DON, confirmed the absence of interventions related to Advance Directives in the resident's electronic medical record. The resident's care plan, last revised on a specific date, lacked documentation for Advance Directives, indicating a failure to adhere to the facility's policy and to address the resident's rights and needs comprehensively.
Failure to Include Advanced Directives in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for Advanced Directives was developed and implemented for a resident, identified as R163. The facility's policy requires that a comprehensive, person-centered care plan be developed by the interdisciplinary team in conjunction with the resident and their family or legal representative. This care plan should include measurable objectives and timetables to meet the resident's needs. However, upon review, it was found that R163's care plan did not include interventions for Advanced Directives, despite the resident's severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Interviews with facility staff, including an LPN and the Administrator and Director of Nursing, confirmed the absence of Advanced Directives in R163's care plan. The LPN was unable to locate any related interventions in the resident's Electronic Medical Record (EMR), and the Administrator and DON acknowledged that R163 was not care-planned for Advanced Directives during their stay at the facility. This oversight represents a failure to adhere to the facility's policy and to ensure that the resident's rights and needs were fully addressed in their care plan.
Failure to Provide Necessary Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident, identified as R52, who was dependent on staff for activities of daily living (ADLs). The facility's policy stated that residents unable to perform ADLs independently should receive appropriate care, including hygiene support. However, a review of R52's task documentation revealed no showers were documented from June through November 2024, indicating a lack of showering during this period. Observations on multiple occasions showed R52 in bed without a shirt, unshaven, and with crusty discharge in the eyes, suggesting inadequate personal hygiene care. Interviews with R52 and staff members confirmed the deficiency. R52 reported not having received a shower since admission in June 2024 and stated he did not refuse showers. A CNA familiar with R52 admitted never offering him a shower, assuming he received bed baths from the previous shift. The unit manager confirmed R52's scheduled shower days and the expectation for staff to offer showers, with refusals documented. Despite this, R52 was not offered showers, highlighting a failure in adhering to the facility's policy and care plan.
Failure to Implement Bed Pad Alarm for Fall Prevention
Penalty
Summary
The facility failed to provide a bed pad alarm for a resident, as outlined in the care plan, following a fall incident. The resident, who was cognitively intact and had a history of orthopedic aftercare, muscle weakness, and mobility issues, was found on the floor by a CNA. The CNA reported the incident to an LPN, who assessed the resident and found no immediate injuries. The care plan for the resident included the use of a bed pad alarm, but observations on two consecutive days revealed that the alarm was not in place. Interviews with staff indicated that the bed pad alarm was not consistently used, and there was confusion about its status, with one LPN admitting the alarm was not in place and another stating it was malfunctioning. The resident's care plan also included other fall prevention measures, such as keeping the bed in the lowest position and ensuring the call light was within reach. However, the resident reported reaching for the call light before the fall. The absence of the bed pad alarm, which was supposed to assist in fall prevention, was a significant oversight. Staff interviews revealed a lack of communication and follow-through regarding the alarm's status, contributing to the deficiency in care. The facility's policy on fall risk management emphasized that alarms should not be the sole intervention, yet the failure to implement the alarm as part of a comprehensive fall prevention strategy was evident.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R68, who was admitted with diagnoses including seizures, overactive bladder, hypertension, chronic pain, and paraplegia. The facility's policy on hydration, last revised in October 2017, mandates that residents should be assessed for hydration needs quarterly and more frequently if necessary, with nursing aides responsible for providing and encouraging fluid intake. However, observations and interviews revealed that R68 was not offered fluids between meals, and documentation showed that on certain dates, there was no record of hydration being provided. On 11/03/24, R68 was observed in bed with two empty cups and reported not receiving fluids between mealtimes. Further review of R68's fluid intake documentation indicated that on 11/03/24, the resident only received 840 milliliters of fluid, which is below the facility's threshold of 1200 ml/day. Additionally, there were multiple dates between 10/07/24 and 11/04/24 with no documentation of hydration. The care plan for R68, last revised on 10/17/24, included monitoring for complications related to a history of stroke, but did not specifically address hydration needs. Interviews with the Administrator and DON confirmed that staff are expected to provide and document hydration throughout the day, as per facility policy.
Failure to Notify Responsible Party of Resident's Wound
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in the resident's condition, specifically the development of an unstageable wound on the resident's left hip. The facility's policy requires that a nurse notify the resident's representative of any significant change in the resident's physical status. The resident, who was admitted with diagnoses including parkinsonism, chronic obstructive pulmonary disease, and type 2 diabetes, had a treatment order for the wound starting on May 17, 2024. However, the responsible party was not informed of the wound until a meeting on May 20, 2024, despite the wound being documented as new and unstageable on May 15, 2024. Interviews with the resident's responsible party and facility staff confirmed the delay in notification. The responsible party stated that she was not informed of the wound until she visited from out of state and met with the Director of Nursing, the Social Worker, and the Wound Nurse. The Wound Nurse acknowledged that the notification occurred during the meeting and not prior to the visit. The Director of Nursing also confirmed that the family member should have been notified before their visit, indicating a lapse in following the facility's notification policy.
Failure to Document Resident Grievance
Penalty
Summary
The facility failed to ensure a written grievance was filed for a resident regarding care concerns, as required by their grievance policy. The policy, revised in April 2017, states that residents, family, and resident representatives have the right to voice or file grievances without discrimination or reprisal. However, a review of the facility's Resident Grievance Log for May 2024 showed no recorded concerns for the resident in question. The resident's personal representative reported having care concerns during a visit, including issues with odors, a fall, a hip wound, and the state of the resident's room. These concerns were communicated to the head of nursing, the social worker, and the wound nurse, who assured the representative that they would address the issues. Interviews with facility staff revealed a lack of proper documentation and follow-up on the reported concerns. The social worker stated that if a concern had been brought to her attention as a grievance, she would have documented it and logged it in the grievance system. The Director of Nursing, who was not in the position at the time of the grievance, confirmed that any care issues should have been documented as a grievance. The wound nurse also acknowledged being present during the meeting with the resident's personal representative, where multiple concerns were raised. Despite the facility's policy and the availability of grievance forms, the concerns were not formally documented, leading to a deficiency in the facility's grievance handling process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orangeburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jolley Acres Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Edisto Post Acute | 4.2 mi | ★★★★★ | 8 | 0 |
| Pruitthealth- Orangeburg | 4.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth- Bamberg | 13 mi | ★★★★★ | 1 | 0 |
| Calhoun Convalescent Center | 16.9 mi | ★★★★★ | 9 | 1 |
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