Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Briarcliff Health Center Of Greenville during CMS and state inspections, most recent first.
Two cognitively intact residents alleged that a CNA was rude, refused requested care such as meal tray delivery, linen changes, and a shower, and roughly transferred one resident by lifting her by her brief and nearly dropping her into bed. One resident reported these concerns to a CNA, who then informed the ADON. Although facility policy required immediate reporting of all abuse allegations to the Administrator and prompt investigation, the ADON did not report the allegation at that time, believing she had addressed the situation by changing the CNA’s assignment. The Administrator only learned of the allegations days later, and interviews confirmed that the residents described rough handling and refusal of care, while the CNA admitted transferring a resident by grabbing the back of her pants without a gait belt and not returning to provide the requested shower. The DON confirmed that abuse allegations were required to be reported immediately to the Administrator and that this did not occur.
Two cognitively intact female residents, one with a right patella fracture and DM2 with hyperglycemia and the other dependent for transfers due to muscle wasting and poor coordination, reported that a CNA was rude, refused care tasks such as providing a meal tray, changing linens, and giving a shower, and transferred one resident by lifting her by her brief and nearly dropping her into bed. A CNA was informed of this alleged mistreatment and relayed it to the ADON, who spoke with the residents but did not immediately notify the Administrator as required by the facility’s abuse reporting policy, which mandates immediate reporting, and no later than two hours, for alleged abuse.
A resident with chronic systolic CHF, adult failure to thrive, and dependence on staff for transfers was assisted from a wheelchair to bed by a CNA who did not use a gait belt and instead lifted the resident by the back of her pants. The resident’s care plan identified the need for assistance with transfers due to muscle wasting and lack of coordination but did not specify required transfer equipment, despite facility policy requiring appropriate lifting techniques and devices. In interviews, the CNA admitted not using a gait belt and acknowledged the safety implications, while the DON and Administrator confirmed that a gait belt was expected for one-person transfers and that nursing administration was responsible for ensuring proper transfer techniques.
A resident with Type II DM and multiple comorbidities was readmitted from the hospital with orders for Insulin Glargine and regular insulin, and instructions to discontinue Tresiba. Facility staff failed to accurately reconcile the hospital discharge medications, did not transcribe the new insulin orders, and continued a prior Tresiba order. An LVN acknowledged the reconciliation and transcription error, and an RN later administered 40 units of Tresiba at HS per the incorrect MAR, after which the resident’s blood glucose dropped to 35. During this hypoglycemic episode, the RN could not locate the emergency kit containing glucagon, despite glucagon being present in the kit later found by the DON, resulting in delayed access to ordered emergency hypoglycemia treatment.
A resident with stroke, diabetes, severely impaired cognition, and dependence for all ADLs had a comprehensive care plan that did not reflect his current transfer status requiring a mechanical lift. The order summary did not include a mechanical lift order, and staff interviews showed the CNA relied on verbal handoff for transfer needs while the MDS nurse confirmed the care plan lacked transfer status and the DON and Administrator stated the missing information could cause injury if staff were unaware of the required transfer process.
A facility failed to remove damaged mechanical lift slings from service for two residents. One resident with severe cognitive impairment and total ADL dependence had a sling with faded straps and bleached stitching left on his wheelchair, and the same sling was still there the next morning. Another resident with moderate cognitive impairment and max transfer assistance had a sling with frayed, torn loops observed under her wheelchair and later in her room. Staff interviews confirmed that worn, frayed, torn, or bleached slings should be removed from use, and facility policy and manufacturer guidance both required slings to be in good condition.
Improper Female Incontinent Care: Two CNAs provided incontinent care to a resident who was always incontinent of urine and bowel and dependent on staff for toileting hygiene. During observed care, the resident’s perineal and rectal areas were wiped in a manner that included wiping from the rectal area toward the urethral area instead of consistently front to back. The CNAs acknowledged the error, and the DON, ADON, and Administrator confirmed that female incontinent care should be performed front to back to reduce infection risk.
Expired medications were found in storage for two residents: one resident’s lorazepam concentrate remained in the med room refrigerator after the order was discontinued and beyond the labeled beyond-use date, and another resident’s ondansetron card remained in the med cart after expiration. Staff stated nurses were responsible for checking meds before administration and removing expired or discontinued drugs, while the DON and Administrator said expired medications should be discarded and that the facility expected its med storage and administration policies to be followed.
Unlabeled OTC Eye Drops in Medication Cart: An observation found an opened bottle of Sodium Chloride Hypertonicity ophthalmic solution 5% on the A hall nurse medication cart that was not labeled with the resident's name. An LVN said she was not sure which resident it belonged to and stated nurses were responsible for labeling OTC eye drops with the resident name and date opened to prevent use on multiple residents. The DON and Administrator said nurses and pharmacists were responsible for ensuring medications were labeled and stored correctly.
Failure to Follow Contact Precautions During Incontinent Care: Staff provided incontinent care to a resident on MRSA contact isolation without wearing gowns, despite a door sign and PPE available outside the room. The resident had cognitive impairment, was dependent for toileting hygiene, and was always incontinent of urine and bowel. Both CNAs acknowledged they should have worn gowns, and facility leadership confirmed gowns and gloves were required for contact precautions.
A resident with multiple pressure ulcers, surgical wounds, and MRSA was admitted with these conditions clearly documented in the MDS assessment, but subsequent skilled evaluation forms completed by nursing staff failed to identify or document any skin issues or infection control precautions. Interviews confirmed that staff did not accurately complete required documentation, resulting in incomplete and inaccurate medical records.
A resident admitted with multiple wounds and a history of MRSA did not have Enhanced Barrier Precautions (EBP) implemented until six days after admission, despite facility policy and staff expectations. Staff interviews revealed inconsistent understanding and application of EBP, with reliance on posted signs or direct communication rather than systematic assessment at admission. The DON confirmed EBP should have been initiated upon admission for residents with open wounds, but this was not done.
A resident with significant mobility limitations was found with ants in her bed and on her body, despite the facility's ongoing pest control program. Staff observed ants on the bed, nightstand, and bed rail, and noted the presence of snacks in the room. The resident was sent to the hospital after being found with bleeding and ants present, and family members reported possible ant bites. The facility's pest control technician responded after the incident, but the deficiency occurred due to the failure to keep the resident's room free from pests.
The facility failed to update comprehensive care plans for four residents, omitting critical information such as diagnoses and medication interventions. This included missing details about anticoagulant use, C-diff precautions, and oxygen therapy. The omissions were acknowledged by the MDS nurses and the DON, who cited a lack of awareness and experience. The facility's policy requires timely updates to care plans, but these were not completed, potentially leading to inadequate care.
The facility failed to update comprehensive care plans for three residents, leading to outdated interventions being listed. A resident's care plan still included a PICC line and antibiotics that were no longer ordered, while another's listed melatonin and shingles-related care that had been discontinued. A third resident's plan included antibiotics and IV fluids no longer needed. The MDS nurses responsible were unaware of these omissions, which could result in unnecessary or inappropriate care.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to proper protocols. A resident with C-diff was not isolated properly, and staff did not use PPE as required. Another resident with a pressure wound was not managed under enhanced barrier precautions, and hand hygiene was neglected during medication administration. These deficiencies were acknowledged by the facility's DON and Administrator.
A facility failed to respect the dignity and privacy of two residents when a laundry aide entered their rooms without knocking or introducing herself. One resident, with moderate cognitive impairment and multiple health issues, and another with intact cognition and quadriplegia, both expressed feeling disrespected. The aide admitted to not following protocol, and the facility's policy requires staff to knock and introduce themselves to ensure residents' comfort and respect.
A facility failed to ensure a resident's call light was within reach, risking unmet needs. The resident, with Alzheimer's and severe cognitive impairment, was observed multiple times with the call light on the floor. Staff acknowledged the oversight, which contradicted the facility's policy requiring call lights to be easily reachable.
A resident with severe cognitive impairment and multiple medical conditions was observed with black material under her fingernails on three consecutive days, indicating a failure in providing necessary nail care. The resident required assistance for personal hygiene, but the facility staff did not adhere to the policy of cleaning and maintaining fingernails, potentially risking bacterial infections.
A resident with severe cognitive impairment and a history of falls was found without a required fall mat beside his bed on multiple occasions, despite a physician's order for its use. Staff interviews confirmed the importance of the mat in preventing falls, and the facility's policy highlighted the need for such interventions, yet the mat was not consistently placed, resulting in a deficiency.
A facility failed to follow a physician's order to change a resident's oxygen tubing weekly, as required for safe respiratory care. The resident, who was receiving continuous oxygen therapy due to congestive heart failure, had undated oxygen tubing, and staff were unaware of the last change. Interviews revealed that charge nurses were responsible for this task, but the care plan lacked specific instructions for oxygen management, leading to the deficiency.
The facility failed to secure a medication cart, leaving it unlocked and unattended while LVN R provided treatment to a resident. This oversight allowed potential access to medications by residents, visitors, or staff. Interviews with the DON and Administrator confirmed that the expectation was for carts to be locked when not in use, aligning with the facility's policy.
The facility failed to maintain food safety standards, as dietary staff did not wear hair restraints properly, risking hair contamination in food. Additionally, the microwave was not kept sanitary, with brown debris observed inside. Staff interviews revealed a lack of awareness about these issues, despite facility policies requiring proper hair restraint use and microwave cleanliness.
A Treatment Nurse failed to change gloves and perform hand hygiene after handling a dirty napkin and oxygen tubing before starting wound care on a resident. This lapse in protocol was confirmed by both the nurse and the DON, highlighting a failure to adhere to the facility's Handwashing/Hand Hygiene policy.
Failure to Report and Investigate Allegations of Abuse and Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse investigation and reporting policy when an allegation of abuse and mistreatment was reported involving two cognitively intact residents. The facility’s policy, revised 10/15/2022, required that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown origin be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The policy also specified that the Administrator would immediately suspend any employee accused of resident abuse pending the outcome of an investigation and that alleged violations involving abuse or serious bodily injury be reported immediately, but not later than two hours. Despite these requirements, staff did not immediately report or initiate the required abuse investigation process when an allegation was made against a CNA. Resident #2, a female resident with a right patella fracture, type 2 diabetes mellitus with hyperglycemia, and an intact BIMS score of 15, reported that CNA A was rude to her and refused to provide care. She stated that on a day she believed to be a Thursday or Friday, she asked CNA A for her breakfast tray and was told that CNA A was her roommate’s CNA, not hers, and the tray was not given by CNA A. Later, when CNA A offered a shower to the roommate, Resident #2 requested that her own bed linens be changed, and CNA A refused. Resident #2 then asked another CNA who was assigned to her care and was told it was CNA A. When CNA A returned to the room, Resident #2 observed that CNA A appeared angry, did not speak to her, and changed only part of her bedding. Resident #2 reported feeling like crying and questioned what she had done to be treated that way. She further reported that when her roommate, Resident #1, asked to be put to bed, CNA A sighed loudly, did not speak, picked Resident #1 up by her brief, and almost dropped her while transferring her to bed, causing Resident #1 to appear scared. Resident #2 told her roommate that she intended to report CNA A’s behavior because she did not want CNA A back in the room and did not want to tolerate abuse. She reported the incident to a nurse and later told CNA B that CNA A had been very rude and mistreated both her and her roommate by refusing to give her a tray, change her sheets, provide a shower, and almost dropping Resident #1 during a transfer. CNA B acknowledged that she was aware abuse should be reported to a nurse or the DON and stated she informed the ADON and asked her to talk to Resident #2. The ADON confirmed that CNA B reported that an aide had been rough with Resident #1 and that Resident #2 felt CNA A had thrown Resident #1 into bed. The ADON stated that Resident #2 did not report mistreatment of herself to her, only of her roommate, and that when she asked Resident #1 if CNA A had hurt her, Resident #1 shook her head no. The ADON admitted that, although allegations of abuse were supposed to be reported immediately to the Administrator, she did not report the allegation because she believed she had addressed the situation by adjusting CNA A’s assignment. The Administrator reported that she was only notified by the ADON several days later that Resident #2 had made a statement about CNA A. Upon speaking directly with both residents, the Administrator learned that Resident #2 said she saw CNA A pick up Resident #1 by the brief and throw her into bed and that CNA A had not given her the breakfast tray she requested. Resident #1 told the Administrator that CNA A entered the room with an attitude, did not speak to her, picked her up to put her in bed, and almost dropped her, and that she did not remember all of the incident but agreed that whatever Resident #2 said had happened was accurate. CNA A, when interviewed, denied refusing to give Resident #2 her tray or shower, stated she did not know Resident #2’s shower schedule, and admitted she did not return to give the shower herself. She also admitted transferring Resident #1 by grabbing the back of her pants without using a gait belt, while denying that she was rough or almost dropped her. The DON acknowledged prior complaints about CNA A’s attitude and confirmed that any allegation of abuse should be reported immediately to the Administrator and that failure to follow the abuse policy placed residents at risk. The deficiency centers on the failure of CNA B and the ADON to immediately report Resident #2’s allegation of abuse and rough handling by CNA A to the Administrator as required by the facility’s abuse policy.
Failure to Immediately Report Resident Abuse Allegations to Administrator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown origin were reported immediately, and no later than two hours when abuse was alleged. A cognitively intact female resident (Resident #2), with a right patella fracture and type 2 diabetes with hyperglycemia, reported that a CNA (CNA A) was rude to her, refused to give her a breakfast tray, refused to change her bed linens when requested, and did not provide a requested shower. Resident #2 stated that CNA A told her she was the roommate’s CNA and not hers, and that another staff member later brought her breakfast tray and another CNA later provided her shower. Resident #2 reported feeling upset and wanting to cry due to how she was treated and questioned what she had done to be treated that way. Resident #2 further reported that during the same day, her roommate (Resident #1), who was cognitively intact and dependent on staff for transfers due to muscle wasting and lack of coordination, asked CNA A to put her in bed. According to Resident #2, CNA A sighed loudly, did not speak, picked Resident #1 up by her brief, almost dropped her while transferring her to bed, and then left the room without speaking to either resident. Resident #2 stated she could tell Resident #1 was scared and that she herself was frantic because she feared her roommate would be dropped and she was unable to help. Resident #2 said she told her roommate that she needed to report CNA A, but the roommate did not want to report. Resident #2 reported that she then informed a nurse about the incident and had not seen CNA A since that day. CNA B reported that Resident #2 told her that CNA A had been very rude and had mistreated both residents by not wanting to give Resident #2 her tray, change her sheets, give her a shower, and by almost dropping Resident #1 during a transfer. CNA B stated she informed the ADON so it could be reported. The ADON confirmed that CNA B told her Resident #2 reported CNA A was rough with her roommate and that Resident #2 felt CNA A threw Resident #1 into bed. The ADON stated she spoke with Resident #1, who shook her head no when asked if CNA A had hurt her, and that she did not report this allegation to the Administrator at that time. The Administrator later stated she was only notified by the ADON several days after the initial allegation and that Resident #2 then reported CNA A picked Resident #1 up by the brief and threw her into bed and refused to give Resident #2 her breakfast tray. The facility’s abuse policy required that alleged violations of abuse, neglect, exploitation, mistreatment, or injuries of unknown source be reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. Despite this policy, the allegation reported by Resident #2 to CNA B and the ADON was not immediately reported to the Administrator as required.
Improper Manual Transfer Performed Without Gait Belt
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistance devices during a transfer for one resident. The resident was an adult female with chronic systolic congestive heart failure and adult failure to thrive, whose MDS showed intact cognition (BIMS 15) and dependence on staff for transfers. Her care plan, revised on 04/01/2026, identified an ADL self-care performance deficit related to muscle wasting and lack of coordination and stated she required assistance with transferring, but it did not specify the type of equipment to be used for transfers. The facility’s policy on Safe Lifting and Movement of Residents required the use of appropriate techniques and devices, including training staff in the use of manual devices such as gait belts. On 04/01/2026, CNA A transferred the resident from her wheelchair to her bed without using a gait belt, instead grabbing the resident by the back of her pants. The resident later reported to the Administrator that the CNA picked her up to put her in bed and almost dropped her, although the resident did not remember all details of the incident. In an interview, CNA A acknowledged she did not use a gait belt, stated she should have used one, and recognized that not using a gait belt could have resulted in the resident getting hurt. The DON stated the resident required one-person assistance for transfers and that a gait belt should be used, and confirmed responsibility for ensuring CNAs transfer residents properly through competency monitoring. The Administrator stated she expected staff to follow policies and procedures and use a gait belt for one-person transfers, and that improper transfers could result in injury.
Significant Insulin Reconciliation Error and Failure to Access Glucagon for Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration and emergency hypoglycemia treatment. The resident, an older male with Type II diabetes mellitus and multiple comorbidities including COPD, chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, gout, and dysphagia, was originally admitted and later discharged following a hypoglycemic episode with a blood glucose level of 35. Upon readmission from the hospital, the discharge instructions included an order for Insulin Glargine 12 units once daily and regular insulin on a sliding scale before meals, with explicit instructions to stop Insulin degludec (Tresiba) 40 units once daily. The facility’s March 2026 MAR showed that these new insulin orders were not transcribed and that the prior order for Tresiba 40 units at bedtime was continued. On the readmission date, LVN A completed admission assessments but did not review the hospital discharge medication list, stating that two nurses typically split admission tasks and that the charge nurse handled the medication review. LVN B, the charge nurse on the readmission date, reported that he completed the medication reconciliation but acknowledged he failed to accurately reconcile the medications and transcribe the correct insulin orders, resulting in continuation of Tresiba instead of initiating Insulin Glargine and regular insulin per hospital instructions. The attending physician later stated he had instructed the facility to follow hospital orders and expected nurses to accurately review discharge instructions and call with accurate information when verifying orders. On the night of the incorrect insulin administration, RN C, who was aware the resident had been readmitted but relied on the prior shift’s reconciliation, followed the existing physician orders and administered 40 units of Tresiba at bedtime after a blood glucose reading of 135. At approximately 5:10 a.m. the following morning, RN C obtained a blood glucose reading of 35. The resident was alert, able to sit upright, and had no difficulty swallowing. RN C administered sugar dissolved in peach juice and water while awaiting EMS. RN C reported being unable to locate the facility emergency kit containing glucagon injection or gel at that time. The DON later confirmed that glucagon gel and an injection were present in the emergency kit in the medication room but required 45 minutes of searching to locate it. The facility’s own policies on medication reconciliation and medication errors defined the need for accurate reconciliation of pre- and post-discharge medications and identified wrong-drug administration as a medication error, which was not followed in this case.
Removal Plan
- Notified the Medical Director of the Immediate Jeopardy.
- Completed a chart audit of all residents with diabetes mellitus to ensure orders were in place for glucagon injection or gel PRN for low blood sugar and signs of hypoglycemia.
- Implemented a Glucagon Audit Sheet to be completed daily by the charge nurse to ensure glucagon is available in the emergency kit.
- Established daily monitoring of the Glucagon Audit Sheet by the DON/ADON during the clinical meeting and by the weekend supervisor/designee on weekends.
- Completed an audit to confirm emergency glucagon orders were in place for all residents with diabetes mellitus.
- Located glucagon medication in the emergency kit in the medication room and re-labeled it with a large red label to allow it to be easily located.
- Implemented a policy requiring two nurses to review medication reconciliation for all new admissions and readmissions.
- Conducted an in-service for DON/ADON regarding the diabetes protocol and medication reconciliation on all admissions.
- Conducted an in-service for all full-time and part-time nurses on accurate medication reconciliation for new admissions/readmissions, the location of the emergency kit glucagon, and hypoglycemia/diabetes protocols.
- Established that DON/ADON will educate all new nursing staff on these trainings before they are allowed to work.
- Conducted an in-service for the weekend supervisor on reviewing medication reconciliation for all new admissions/readmissions and the location of the emergency kit glucagon.
- Implemented monitoring that the DON or designee will review each new admission physician order for accurate transcription at the daily clinical meeting.
- Implemented monitoring that the weekend supervisor or designee will monitor physician orders on weekends.
- Implemented weekly monitoring by the Regional Clinical Nurse during Quality Improvement reviews to ensure the plan of removal education remains in place.
- Implemented oversight by the Administrator to ensure IDT members review physician orders for all new admissions/readmissions at the clinical meeting and review effectiveness at the monthly QAPI meeting.
- Completed a QAPI meeting and implemented a Performance Improvement Plan in conjunction with the Plan of Removal.
Care plan did not reflect mechanical lift transfer status
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for Resident #4 that reflected his current transfer status. Resident #4 was a male resident admitted with diagnoses of cerebral infarction (stroke) and diabetes. His quarterly MDS assessment dated 01/29/2026 showed a BIMS of 00, indicating severely impaired cognition, dependence on staff for all ADLs, use of a wheelchair, and functional limitation of range of motion in both upper and lower extremities. The comprehensive care plan, revised on 02/05/2026, did not reflect that he required a mechanical lift for transfers on admission or at the time of revision. Record review of the order summary report showed an order for out of bed twice daily and as tolerated two times a day for pain, but no order related to mechanical lift use. During interviews, a CNA stated she relied on verbal reports from other CNAs and charge nurses rather than a Kardex for transfer requirements, and said Resident #4 required a mechanical lift because he was dependent for all transfers. The MDS nurse stated there was no transfer status on the admission or revised care plan and that it would be corrected to reflect two-person transfers with a mechanical lift. The DON and Administrator both stated that not having the correct transfer status on the care plan could cause injury if staff were not aware of the required transfer process.
Damaged mechanical lift slings left in use
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accident hazards as possible when it did not remove worn and damaged mechanical lift slings from service for two residents. For one resident, record review showed severe cognitive impairment, dependence on staff for all ADLs, wheelchair use, and limited range of motion. His care plan did not reflect the current transfer status requiring a mechanical lift, and his order summary did not include transfer status or mechanical lift use. During observation, he was sitting in a wheelchair with a lift sling that had faded straps and lightened stitching, and the same bleached sling was still on the wheelchair the next morning ready for use. For the second resident, record review showed moderate cognitive impairment and maximum assistance needed for transfers, with the care plan identifying her as dependent on staff for transfer. During observation, she was sitting in her wheelchair with a lift sling under her that had frayed and torn loops. The sling was again observed in her room the next morning with frayed and torn loops. Later that morning, she was observed in therapy without the sling under her because she was stronger and did not need the mechanical lift at that time. Interviews confirmed staff awareness that damaged slings should be removed from service. A CNA stated she was unsure about the faded straps on one sling and would ask the nurse about taking it out of service. Another CNA said slings should be inspected before use and that frayed or torn slings should be given to the nurse and replaced. The DON, Administrator, and Housekeeping Supervisor all acknowledged that the faded sling and the frayed or torn sling should be removed from service, and the Housekeeping Supervisor stated laundry staff would be trained on sling care, including air drying and not using bleach. Facility policy required slings to be in good condition and to discard worn, frayed, or ripped slings, and manufacturer guidance stated that faded, bleached, torn, or frayed slings should be immediately removed from use.
Improper Female Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was always incontinent of urine and bowel and dependent on staff for toileting hygiene. The resident had a colostomy status, anorexia nervosa, hypertension, moderate impairment in thinking with a BIMS score of 8, and a care plan noting prophylactic medications for recurrent UTIs. During an observation, two CNAs provided incontinent care to the resident. After removing the resident's brief and gloves, one CNA wiped the resident's inner thighs and then wiped the vaginal area from front to back. The resident was then rolled onto her side, the soiled brief was removed, and the CNA wiped the resident's buttocks and rectal area in a manner that included wiping from the rectal area toward the back and then wiping the rectal area down the middle from back to front toward the urethra. In interviews, both CNAs acknowledged the care was not performed correctly and stated that female incontinent care should be done from front to back. The ADON, DON, and Administrator each confirmed that staff should wipe from front to back during female incontinent care and that improper technique could lead to infections, including UTIs. The facility policy for perineal care also stated that for a female resident, the perineal area should be washed wiping from front to back.
Expired Medications Left in Storage Areas
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for two residents reviewed for pharmacy services. For one resident with polyneuropathies and severe cognitive impairment, a bottle of lorazepam concentrate remained in the medication room refrigerator even though the order had been discontinued and the label indicated it was to be discarded 90 days after opening; the bottle had been opened months earlier and the last dose had been given after the discontinuation date. For another resident with traumatic subdural hemorrhage and severe cognitive impairment, an active PRN order for ondansetron remained on the medication record, but a card of ondansetron in the medication cart had expired and was still present during observation. During interview, an LVN stated nurses were responsible for checking medication carts and locked boxes, verifying each medication before administration, and removing expired or discontinued medications for disposal. The DON stated she and the ADON checked carts and lock boxes periodically without a set schedule, and that the pharmacist checked carts monthly and removed expired medications. The Administrator stated nurses and pharmacists were responsible for ensuring medications were discarded after expiration and that expired medications should be removed and discarded. Facility policies stated the expiration or beyond-use date must be checked before administering medications, opened multi-dose containers must be dated, and discontinued, outdated, or deteriorated drugs must be returned to the dispensing pharmacy or destroyed.
Unlabeled OTC Eye Drops in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. During an observation on [DATE] at 11:30 am, the medication cart for hall A contained an opened bottle of Sodium Chloride Hypertonicity ophthalmic solution 5% that was not labeled with the name of the specific resident it had been ordered for. The report states this was 1 of 4 medication carts reviewed for labeling and storage, and the unlabeled OTC eye drops were found on the A hall nurse medication cart. During interviews, LVN E said she was not sure what resident the eye drops belonged to and stated nurses were responsible for labeling OTC eye drops with the resident's name and date opened so they would not be used on multiple residents. She said nurses should check their carts each shift and before administering medications to ensure the medication was for the correct resident, not expired, and labeled correctly. The DON said she and the ADON checked medication carts periodically for unlabeled medications but there was no set schedule, and the pharmacist checked all carts monthly and removed unlabeled medications. The Administrator said nurses and pharmacists were responsible for ensuring medications were labeled and stored correctly, and that eye drops should be labeled with resident name and date opened to ensure single resident use.
Failure to Follow Contact Precautions During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for infection control. Resident #72 was admitted with diagnoses including colostomy status, anorexia nervosa, and hypertension. Her quarterly MDS indicated moderate impairment in thinking with a BIMS score of 8, dependence on staff for toileting hygiene, and that she was always incontinent of urine and bowel. Her care plan and physician orders indicated she was on contact isolation for MRSA in urine, with PPE required before entering the room. During an observation, CNA D and CNA F were in the resident’s room providing incontinent care. The resident’s door had a contact precautions sign and PPE was available in the hallway, and both staff sanitized their hands and applied gloves, but neither donned a gown during the care. In interviews, both CNAs stated they should have worn a gown because the resident was on contact precautions and acknowledged they did not notice the sign or PPE container. The DON, ADON, and Administrator stated that staff should wear a gown and gloves for residents on contact precautions and that the resident was on contact isolation for an infection in her urine. The facility policy on transmission-based precautions stated that staff and visitors wear a disposable gown upon entering the room and remove it before leaving.
Incomplete and Inaccurate Documentation of Resident Skin Conditions
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex medical conditions, including a right femur fracture, several pressure ulcers, MRSA, right lung cancer, post-operative anemia, and osteoporosis. Upon review, the resident's admission MDS assessment documented the presence of surgical wounds and multiple pressure ulcers. However, subsequent Skilled Evaluation assessments completed by nursing staff did not identify or document any skin issues, surgical wounds, or infection control precautions, despite the resident's known conditions. Interviews with nursing staff confirmed that the skilled evaluation forms should have reflected these active skin concerns and infections, but they were not properly documented. Further interviews with the Director of Nursing and the Administrator revealed an expectation that nursing staff accurately identify and code current skin issues and infection control concerns on daily skilled charting. The facility had recently changed assessment forms, which was noted as a possible contributing factor to the documentation errors. The facility's policy requires that medical records be complete and accurately document residents' medical conditions, but this was not followed in this instance, resulting in incomplete and inaccurate records for the resident.
Failure to Timely Implement Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who was admitted with multiple wounds and a history of MRSA. Upon admission, the resident had a right femur fracture, several pressure ulcers, a deep tissue injury, and a recent surgical history, including a hip replacement and right lung lobectomy. Despite these risk factors, Enhanced Barrier Precautions (EBP) were not implemented until six days after admission, as evidenced by the Medication Administration Record and order summary. Staff interviews revealed inconsistent understanding and implementation of EBP, with several nursing assistants and licensed nurses relying on posted signs or direct communication to determine when EBP was required, rather than a systematic approach at admission. The Director of Nursing acknowledged that EBP should have been initiated upon admission for residents with open wounds, and could not explain the delay in this case. The facility's infection control policy required transmission-based precautions when standard precautions were insufficient, but this protocol was not followed for the resident in question. The deficiency was identified through record review and staff interviews, which confirmed that the lack of timely EBP implementation placed the resident and others at risk for cross-contamination and infection spread.
Failure to Maintain Effective Pest Control Resulting in Ants in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident's room not being free from ants. The resident, a cognitively intact female with significant mobility limitations and dependent on staff for transfers and bed mobility, was found with ants in her bed and on her body. Staff observed ants on the resident's nightstand, bed rail, and bed, and noted that the resident had snacks in her room. The presence of ants was first reported on the facility's insect report sheet, and staff interviews confirmed that ants were seen on and around the resident during care. Nursing notes documented that the resident was found with medium bleeding from the perineal area and ants present on her bed and thigh. The resident was subsequently sent to the hospital, where EMS reported that she had been lying in a bed covered with ants. Hospital records indicated blood in the resident's urine and stool, and family members reported that the resident stated she had been bitten by ants. Observations at the hospital revealed small red areas on the resident's hand that could have been ant bites, although no definitive bites were confirmed by staff. Facility records showed that pest control services were provided monthly, and the pest control technician responded after the incident, finding one dead ant and placing bait in the room. Staff interviews indicated that the room was cleaned and sprayed after the resident was sent to the hospital, and that the presence of snacks may have contributed to the ant activity. Despite regular pest control measures, the facility did not prevent the occurrence of ants in the resident's room, leading to the deficiency.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. Resident #90's care plan did not include his diagnosis and interventions for the medication Eliquis, an anticoagulant. This omission placed him at risk for not being monitored for side effects. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for accurate care plans, especially for medications like anticoagulants. Resident #95's care plan did not include her diagnosis of Clostridioides difficile (C-diff) and the necessary precautions. This oversight could have led to inadequate infection control measures. Similarly, Resident #98's care plan was missing information about his use of Eliquis for atrial fibrillation, and Resident #203's care plan lacked details about her oxygen use for congestive heart failure. These omissions were acknowledged by the MDS nurses responsible for updating the care plans, who cited a lack of awareness and experience as contributing factors. Interviews with the MDS nurses and the DON revealed that care plans were expected to be updated promptly, ideally within a week of any changes. The facility's policy emphasized the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. However, the failure to update these care plans as required could have resulted in staff not being fully informed about the residents' care needs, potentially leading to inadequate care.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #90's care plan was not updated to reflect the discontinuation of a PICC line and antibiotic administration, which were no longer ordered. This oversight could lead to the resident receiving unnecessary care. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for care plans to be accurate and updated within a week of any order changes. Resident #203's care plan was not updated to remove interventions related to melatonin and a rash from shingles, both of which were no longer applicable as the orders had been discontinued. The MDS nurse responsible for updating care plans was unaware of these omissions, which could result in staff providing care that is no longer needed. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in this case. Resident #8's care plan included outdated interventions for antibiotics and IV fluids, which were no longer ordered. The MDS nurse responsible for this resident's care plan was new to the position and missed updating these changes. The Administrator emphasized the importance of accurate care plans to ensure residents receive appropriate care. The facility's policy mandates that care plans be updated with any new orders or changes, but this was not consistently followed, leading to potential risks for the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper infection control protocols. For Resident #95, who was diagnosed with Clostridium difficile (C-diff), staff members, including a CNA, LVN, and a therapist, did not follow contact isolation procedures. Despite signs indicating the need for personal protective equipment (PPE), staff entered the resident's room without wearing the required PPE. The resident herself was under the impression that she was no longer on contact isolation, although the facility physician confirmed she was still being treated for C-diff and should have been in isolation. Resident #203, who had a Stage 3 pressure wound, was supposed to be under enhanced barrier precautions (EBP). However, a CNA and a treatment nurse failed to adhere to these precautions. The CNA did not wear PPE while assisting the resident, and the treatment nurse did not perform hand hygiene between glove changes during wound care. This lack of adherence to infection control protocols was also observed with Resident #64, where a CNA did not change gloves or perform hand hygiene during incontinent care. Additionally, CMA S failed to perform hand hygiene before and after administering medications to Residents #20, #21, and #74, including eye drops for Resident #21. LVN A also did not follow EBP while administering IV medication to Resident #98, as she did not wear a gown. These deficiencies in infection control practices were acknowledged by the facility's DON and Administrator, who recognized the risk of infection due to improper care practices.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the actions of a laundry aide who did not knock, introduce herself, or explain her presence when entering the rooms of two residents. Resident #20, a female with moderate cognitive impairment and multiple health issues, including type 2 diabetes and heart failure, expressed dissatisfaction with staff entering her room without knocking. Similarly, Resident #74, a male with intact cognition and conditions such as quadriplegia and sick sinus syndrome, felt disrespected by the staff's failure to knock before entering his room. The laundry aide admitted to not following protocol, acknowledging the importance of knocking and introducing herself to ensure residents' comfort and respect. The Director of Nursing (DON) and the Administrator both confirmed that staff are expected to knock, introduce themselves, and explain their actions to residents, as per the facility's policy on dignity. The facility's policy emphasizes respecting residents' private space and property by knocking and requesting permission before entering their rooms.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to receive services with reasonable accommodation of her needs and preferences. Specifically, the treatment nurse did not ensure that the resident's call light was within reach from 11/17/24 to 11/19/24. This oversight could have resulted in the resident's needs going unmet. The resident, who was an elderly female with Alzheimer's, high blood pressure, a history of falling, and anxiety, was observed multiple times with her call light on the floor, out of reach. Despite her severe cognitive impairment, she was usually able to understand others and make herself understood, and she required substantial assistance with transfers and toileting. During observations, the resident was found in her bed with the call light on the floor, and she expressed difficulty in calling for help. Staff, including an LVN and the DON, acknowledged that the call light should have been within reach and that all staff entering the room were responsible for ensuring this. The facility's policy on the resident call light system, revised in June 2023, stated that the call light should be easily reachable by the resident to respond to their requests and needs. The failure to adhere to this policy placed the resident at risk of not receiving timely assistance.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and multiple medical conditions, was observed on three consecutive days with black material under her fingernails. The resident required assistance from two persons for dressing, bathing, and personal hygiene, as indicated in her care plan. Despite this, the necessary nail care was not provided, which could potentially lead to hygiene-related issues. Interviews with facility staff, including CNAs and the DON, revealed that it was the responsibility of the CNAs to clean residents' fingernails during showers or as needed. The staff acknowledged the importance of maintaining clean fingernails to prevent bacterial infections, especially since the resident could put her hands in her mouth. The facility's policy on nail care emphasized cleaning the nail bed, trimming nails, and preventing infections, but this was not adhered to in the case of the resident in question.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that the environment for a resident remained free of accident hazards, specifically by not placing a fall mat beside the resident's bed as required. The resident, an elderly male with severe cognitive impairment and a history of falls, was observed on multiple occasions without the fall mat, despite having a physician's order for it to be in place every shift. This oversight was noted on three separate days, during which the resident was found in bed without the protective mat. Interviews with staff, including an LVN and the DON, confirmed that the fall mat was a necessary intervention to prevent falls and injuries. The staff acknowledged the importance of the mat and the responsibility of all staff members to ensure it was in place. The facility's policy on falls emphasized the need for identifying residents at risk and implementing interventions, yet the required intervention for this resident was not consistently followed, leading to a deficiency in care.
Failure to Adhere to Oxygen Tubing Change Protocol
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not adhering to the physician's order to change oxygen tubing weekly on Saturday nights. This oversight was identified for a resident who was receiving continuous oxygen therapy via nasal cannula due to congestive heart failure. The resident's medical history included conditions such as atrial fibrillation, stroke, high blood pressure, and anxiety, and she was severely cognitively impaired. Observations revealed that the oxygen tubing was not dated, and staff were unaware of when it had last been changed, indicating a lapse in following the prescribed schedule for changing and dating the tubing. Interviews with facility staff, including an LVN, the DON, and the Administrator, confirmed that the responsibility for changing and dating the oxygen tubing lay with the charge nurses, who were expected to follow the physician's orders. The facility's policy on oxygen administration emphasized the importance of verifying physician orders and reviewing the resident's care plan. However, the care plan for the resident in question did not include specific instructions for oxygen management, contributing to the deficiency. The failure to change and date the oxygen tubing as required could lead to infection control issues, as acknowledged by the staff.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys. Specifically, LVN R left the Hall 100 medication cart unlocked and unattended in the hallway while providing a treatment to a resident. This oversight occurred when LVN R was distracted and forgot to lock the cart, which was left with the door closed. LVN R acknowledged the risk this posed, as it allowed the possibility for residents, visitors, or staff to access the cart and potentially ingest medications. Interviews with the Director of Nursing (DON) and the Administrator revealed that their expectations were for medication carts to be locked when not in direct vision or use. Both acknowledged that the failure to secure the cart posed a risk for wandering residents to access harmful medications or supplies, as well as the potential for drug diversion or theft. The facility's policy, revised in April 2019, clearly stated that drugs and biologicals should be stored in locked compartments and that unlocked medication carts should not be left unattended.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Specifically, dietary staff did not wear hair restraints appropriately, which could lead to hair contaminating the food. During observations, one staff member was seen with hair visible outside of the hairnet, and another staff member was not wearing a hairnet at all while in the kitchen. Interviews with the staff revealed that they were unaware of their non-compliance with hair restraint policies, although they acknowledged the importance of wearing hairnets to prevent hair from getting into the food. Additionally, the facility did not maintain the microwave in a sanitary condition, as it was observed to have brown debris inside. The Dietary Manager confirmed that the microwave should be cleaned daily to prevent cross-contamination and acknowledged that the current microwave had some damage, necessitating the order of a new one. The facility's policies on employee sanitation and microwave maintenance, dated 2018, require hair restraints to prevent hair from contaminating food and mandate that the microwave be kept sanitary to minimize food hazards.
Infection Control Lapse by Treatment Nurse
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of a Treatment Nurse. During an observation, the Treatment Nurse was seen grabbing a dirty napkin off a bedside table and picking up oxygen tubing from the floor without changing gloves or performing hand hygiene before starting wound care on a resident. This lapse in protocol was confirmed during an interview with the Treatment Nurse, who acknowledged that his gloves would have been contaminated after handling the napkin and tubing. The Director of Nursing (DON) also confirmed that staff are expected to perform hand hygiene and change gloves after touching potentially contaminated items to prevent cross-contamination. The facility's Handwashing/Hand Hygiene policy, revised in December 2023, emphasizes the importance of hand hygiene in preventing the spread of infections. The policy specifies that hand hygiene should be performed before and after direct contact with residents, before handling clean or soiled dressings, and after contact with objects in the immediate vicinity of the resident. The policy also states that the use of gloves does not replace hand hygiene. Despite this policy, the Treatment Nurse's failure to follow proper hand hygiene protocols could place residents and staff at risk for cross-contamination and the spread of infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenville Health & Rehabilitation Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Greenville Gardens | 0.4 mi | ★★★★★ | 14 | 0 |
| Legend Healthcare And Rehabilitation - Greenville | 2.1 mi | ★★★★★ | 5 | 0 |
| Royse City Medical Lodge | 11.2 mi | ★★★★★ | 6 | 0 |
| Farmersville Health And Rehabilitation | 13.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.