Aegis Living Greenwood

A resident with a do-not-resuscitate directive died unexpectedly after staff failed to implement the Negotiated Service Agreement requiring hourly status checks, missing three consecutive hourly checks on the evening of death. The facility conducted a thorough investigation that ruled out abuse/neglect and confirmed the resident passed away peacefully with no signs of injury. The facility's investigation was comprehensive and timely, though the systemic failure to implement agreed-upon care protocols represents a significant lapse in care delivery that could have resulted in delayed response to a medical emergency.

The facility failed to secure harmful products from cognitively impaired residents in two Memory Care Unit bathrooms, placing 24 residents at risk. This represents a repeat violation previously cited on July 11, 2025, indicating a pattern of non-compliance. The facility's inadequate response to the initial citation resulted in an uncorrected deficiency requiring a $300 civil fine and follow-up enforcement action. The repeat nature and lack of sustained corrective action demonstrates minimal facility responsiveness to known safety risks.

The facility had two minor compliance violations: one staff member completed online-only CPR training without the required hands-on component, and another staff member's TB testing was delayed 18 days beyond the required 3-day timeframe. The facility promptly investigated both issues when identified, confirmed the deficiencies through staff interviews and record review, and submitted corrective action plans. A follow-up inspection on 05/13/2025 confirmed all deficiencies were corrected and the facility met licensing requirements.

The facility committed a serious medication error involving an anticonvulsant (Depakote) where the named resident received half the prescribed dose for 3.5 months due to nurse transcription error (92 missed doses), plus an additional 22 missed doses due to medication unavailability - totaling 114 missed doses of a critical seizure medication. The facility conducted a thorough investigation that substantiated the errors and ruled out abuse/neglect, demonstrating an appropriate investigative response, though the systemic failure to catch a transcription error for over three months and medication supply issues indicate significant gaps in medication management oversight. Citations were issued on 08/05/2024.

The inspection identified multiple moderate procedural violations including failure to obtain pet vaccination records, unsecured resident confidential information in an unlocked office, unattended housekeeping carts with accessible cleaning chemicals in areas with cognitively impaired residents, and incomplete TB screening for one staff member. The facility responded appropriately by conducting a timely investigation, submitting a plan of correction within two weeks, and successfully remediating all deficiencies by the follow-up inspection on 11/22/2023, demonstrating good corrective action and systemic improvements.

A memory care resident with a history of two previous elopements was able to unsafely elope a third time due to the facility's failure to provide required monitoring per the resident's assessment and service agreement. This represents a severe systemic failure in wandering prevention for a vulnerable dementia resident, with significant potential for serious harm or death. The facility conducted an investigation and acknowledged the monitoring failure, but the recurrence despite previous incidents suggests incomplete corrective actions and inadequate follow-through on prior elopement prevention measures.