Inspectors visiting Kadima Rehabilitation & Nursing at Greenville on January 27, 2026, found the bag beneath Resident R1's bed at 11:44 in the morning.
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Nobody wrote down what happened or checked whether he had been harmed.
The resident, identified in inspection records only as Resident #1, left the building without staff authorization.
Physical Therapy Assistant A told inspectors the bed and all the equipment around it were broken or non-usable.
Federal inspectors cited the facility following a complaint inspection conducted January 29, 2026.
That is what federal inspectors documented at Citizens Care Center following a complaint survey completed January 29, 2026.
The resident could not make medical decisions independently.
The incident began simply enough.
The resident, identified in inspection records only as Resident B, has lived with Alzheimer's disease, dementia, and delusional disorder.
Inspectors cited the facility for failures in multiple areas governed by the home's own job descriptions and care standards.
The nursing assistant, identified in inspection records only as CNA #5, said she had no idea the resident's transfer status had changed.
The facility's own policy requires residents be provided with communication systems that directly call staff members or a centralized workstation.