Garden City Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 12 sampled residents (Resident 1 and Resident 2) when insulin (a medicine that helps control blood sugar) orders lacked parameters for licensed nurses regarding when to notify the physician and when to hold insulin administration for abnormal blood glucose levels. This failure had the potential to result in inconsistent clinical decision-making, inappropriate insulin administration, and adverse outcomes, including hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 37 sampled residents (Resident 12, Resident 54, Resident 71, and Resident 79) were provided with reasonable accommodation of needs when;1. Resident 12, Resident 54 and Resident 79's call light (device used to contact staff for assistance) was not within reach; and,2. Resident 71 was not provided with a communication board (Communication boards help people communicate with others by using symbols, pictures, or photos). This deficient practice placed Resident 12, Resident 54, Resident 79 and Resident 71 at increased risk for unmet care needs, delayed staff response, and had the potential to impact their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent implementation of its Advance Directive (a legal document that outlines the preferences for medical treatment if the resident become unable to communicate or make decisions for one's self) process for nine of 37 sampled residents (Residents 142, 138, 78, 137, 139, 103, 105, 117, and 3); when Section D of the Physician Orders for Life-Sustaining Treatment (POLST) (POLST, a signed medical order reflecting a resident's life-sustaining treatment preferences) was incomplete and/or the documentation regarding Advance Directive status was inconsistent with other facility records. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were handled, destroyed, and documented in accordance with accepted standards of practice and facility's policy with a census of 101 residents when:1. Destruction and disposition of non-controlled (non-opioid) prescription medications were not co-signed and witnessed by two licensed nurses;2. Medications labeled as hazardous (medications that pose health risks with repeated unsafe handling) were not handled safely during medication administration for Resident 146; and3. [...]

Inspectors wroteBased on observation, Interview and record review the facility failed to ensure safe medication storage practices in the medication carts, Medication refrigerators and medication rooms with resident census of 101 when:1. South hall medication refrigerator stored undated and outdated medications with extensive frost build up and not meeting the temperature range per policy.2. South hall medications cart 3 stored undated and outdated medications.3. North hall medication cart for IV (Into the Vein) stored unlabeled IV solutions.4. North hall medication refrigerator stored discontinued, unlabeled, outdated medications, and co-mingled medication container with different routes of administration, and the storage practices did not follow manufacturer specification for storage temperature.5. South hall medication cart 4 stored undated and outdated medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention practices and provide a clean and sanitary environment with a census of 101 residents when:1. Two water dispensers located at the nurse's stations were found dirty,2. Urinal was not labeled for Resident 9, Resident 98 and Resident 116,3. A pill cutter (a small, handheld device designed to accurately divide pills or tablets into smaller, more manageable doses) was found with unknown powder and dust inside,4. A glucometer (a device for measuring the concentration of glucose in the blood) was cleaned with bare hands using bleach wipes. These failures had the potential to spread disease and illness amongst the residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document informed consent (giving permission for medical care after fully understanding it) for psychotropic medications (drugs that affect how a person thinks, feels, or acts) use for 1 of 37 sampled residents (Resident 148) when Resident 148's medical record lacked evidence that Resident 148 was informed of the purpose, risks, benefits, side effects, alternatives, and provided consent for two antidepressant medications (medications that help improve mood) and one sleep aid medication (medication to help induce sleep). This failure had the potential to result in Resident 148 receiving psychotropic medications without understanding avoidable adverse outcomes including adverse drug effects (unwanted or harmful reactions caused by a medication) and a decline in functioning and/or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of bedside medication storage and use in one out of seven residents (Resident 63) observed for medication administration based on facility's policy and medical doctor's orders when Resident 63 was self-administering a nasal spray medication that was stored at her bedside without a physician's order or the facility staff being aware of the use. This failed practice and use of medication without a doctor's order could contribute to unsafe medication use in a room shared with another resident and possible drug-drug interaction with prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a home-like environment for two of 37 sampled residents (Resident 116 and Resident 127) when:Resident 116's drawer handle was broken; and,Resident 127's walls were not maintained and painted evenly. These failures had the potential to negatively impact Resident 116 and Resident 127's home-like environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 37 sampled residents (Resident 7) was appropriately discharged when Resident 7 was discharged back to a General Acute Care Hospital (GACH) for insurance purposes. This deficient practice resulted in an inappropriate GACH admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - clinical assessment tool used in nursing homes) diagnostic assessments were accurately documented for 2 out of 5 residents reviewed for unnecessary medications, when Resident 2 and Resident 105 received medications for physician-documented conditions that were not coded on the MDS.This failure had the potential to compromise safe and accurate resident assessment and nursing plans of care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received pain management interventions in accordance with assessed pain levels for 1 out of 5 residents reviewed for unnecessary medications, when staff administered PRN (as needed) pain medication for Resident 86 despite documented pain assessments indicating a pain level of 0 (a 0-10 pain scale with 0 being no pain, to 10 being the worst pain). This failure had the potential to result in unnecessary medication administration, increased risk for adverse medication effects, and inaccurate pain assessment.

Inspectors wroteBased on interview and record review, the facility failed to maintain one of four sampled residents' privacy (Resident 1) when licensed nurse (LN) 3 used her personal phone to take a photograph of Resident 1. This failure resulted in a violation of Resident 1's privacy, potentially negatively affecting his psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) environment was free of accident hazards when Resident 1's right wrist remained in an arm positioning device (a medical tool that holds a patient's arm in a specific, stable, and extended position during the procedure and does not allow for movement) following a mid-line insertion (medical procedure of placing a thin, flexible tube (catheter) into a large vein in the upper arm, with the tip terminating just below the armpit). This failure had the potential for injury related to the arm positioning device being secured to Resident 1's bedframe, potentially negatively affecting Resident 1's health, safety, and emotional well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement appropriate safety interventions including supervision to ensure a safe environment free of accidents and hazards for one of two sampled residents (Resident 1) when:1. Resident 1 was not initially assessed (around the time of admission to the facility) accurately for an elopement risk (the potential for a vulnerable individual to leave a facility without staff awareness, leading to serious dangers like injury or even death) and Resident 1 was not reassessed for an elopement risk after Resident 1 became more confused, began to wander (aimless movement), and attempted to and expressed a desire to leave the facility on several occasions; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to use safe lifting technique to move one of two sampled residents (Resident 1) from the wheelchair to the bed on 7/5/25, after Resident 1 had an assisted fall (a situation where a resident begins to fall but is supported or guided by another person to minimize the impact of the fall) to the ground. This failure resulted in Resident 1 sustaining a left distal femoral fracture (broken bone in the lower part of the left thigh bone near the knee).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure self-administration of medication was clinically safe and appropriate for one of three residents (Resident 1), when Resident 1 was not assessed for self- administration of his medications prior to being provided his medications to self-administer while out on pass. This failure had the potential to contribute to unsafe medication use by Resident 1 and could have led to Resident 1 experiencing adverse health consequences.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a plan to address initial goals on admission and physician orders to ensure safety and well-being of a resident) for self-administration of medication for one of three sampled residents (Resident 1) when, Resident 1 was self-administering his multiple medications given to him by facility staff while out on pass from the facility. This failure resulted in a person-centered care plan with individualized interventions not being developed for Resident 1 and had the potential for Resident 1 to not properly self-administer his medications which could have led to subsequent adverse health events.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services after an unwitnessed fall for one of three sampled residents (Resident 1) when: 1. Resident 1 was found on the floor next to his bed on 12/5/24 at 1:25 a.m., with signs of delirium (a sudden, severe change in mental state which can include confusion, disorientation, and an inability to think clearly) and Licensed Nurse (LN) 1 delayed notifying the physician until 7:00 a.m. on 12/5/24; and, 2. LN 1 documented Resident 1 was experiencing signs of delirium after an unwitnessed fall but did not document a neurological (to evaluate level of alertness, orientation, mood), pain, or skin evaluation (to evaluate for trauma, scratches, bruising) was completed. These failures had the potential for Resident 1 to experience pain, suffering, and an increased length of recovery and rehabilitation.

Inspectors wroteBased on interview and record review, the facility failed to provide comprehensive and effective pain management, for one out of three sampled residents (Resident 1) when Resident 1's pain assessment scale (a tool used to assess the level of pain) indicated moderate pain, and Resident 1 was administered a pain medication intended for mild pain. This failure had the potential for Resident 1's pain not being effectively managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident rights to be free from abuse (verbal, mental, sexual, or physical abuse) and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) for two of twenty-one sampled residents (Resident 32 and Resident 38) when the facility was aware that Resident 32 and Resident 38 were continuing to engage in sexual activity which began on or around [DATE] and: 1. The facility did not determine if Resident 32 and Resident 38 had the capacity for sexual consent (physical and psychological actions that involve sexual arousal, desire, and satisfaction); 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen's commercial can opener blade was clean and free from metal shavings. This failure could have resulted in food borne illness (vomiting, diarrhea, nausea) for 98 residents who ate food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to a dignified existence when one resident (Resident 49) in a sample of 21 was exposed to hearing her roommate and another resident engage in sexual activity in their shared room at the facility. The facility was aware of the situation, yet failed to address the issue. This failure led to Resident 49 feeling humiliated and embarrassed and had the potential to negatively impact her psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were investigated and safeguards were implemented to prevent further abuse for two of 21 sampled residents (Resident 25, and Resident 311) after the facility was made aware of an allegation of verbal abuse and the threat of physical violence involving Resident 311 and Resident 25. These failures placed Resident 311 and Resident 25 at risk for unidentified and ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use and storage of Emergency kits (or Ekit, a collection of emergency medications) for a census of 98 residents when: 1. Three Emergency kits (Ekit) for IV (Intravenous, Into the Vein) medications at facility's North Station were open and/or unsealed with no documentation on when it was opened, what was removed, or the medications used for specific residents. 2. Two Emergency kits (Ekit) for refrigerated medications containing a controlled drug called lorazepam (or Ativan, a restricted medication in injectable form used for anxiety or seizure- uncontrolled brain activity) were opened, used, and unsealed with no documentation on when or who it was used for. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in medications carts for a census of 98 when: 1. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in the medication cart at North station with no warning label on how to be handled by nursing staff and without being in a protective bag. 2. A cart designed as an extra IV medication cart (IV is Intravenous, Into the Vein) stored a large supply of prescription IV medications bags with no patient specific label in the facility's North station and without a way to track each IV medication bag and what it was used for. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide infection prevention and control measures to prevent the possible spread infection for a census of 98 when: 1. Appropriate Enhanced Barrier Precautions (EBP-infection control interventions to reduce the spread of germs through gown and glove use during high contact resident care activities) were not followed for Resident 300 and Resident 60 when accessing Peripherally Inserted Central Catheter (PICC-a tube inserted into a vein and guided into a large vein above the heart, used to administer intravenous medication ) lines for intravenous (IV- an apparatus used to administer a fluid such as medication) antibiotics (medication used to treat bacterial infections); and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 37) had her call light (a handheld device that allowed Resident 37 to communicate with nurses and caregivers in the facility setting) within reach. This failure resulted in Resident 37 not being able to reach staff when she needed assistance on 10/21/24 and could have resulted in injury due to her needs not being met in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the state survey agency after the allegations of abuse were witnessed by staff and reported to facility administration involving four of twenty-one sampled residents (Resident 32, Resident 38, Resident 25, and Resident 311) when; 1. Resident 32 and Resident 38 engaged in sexual activity, but neither Resident 32 or Resident 38 had the decision-making capacity (the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention) to consent to the sexual activity; and, 2. Resident 311 was involved in a verbal altercation, which included threats of physical violence and racial derogatory remarks, with her roommate, Resident 25, in their room, on 10/6/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 21 sampled resident's (Resident 20) Preadmission Screening and Resident Review (PASARR - an assessment tool that evaluated Resident 20 for serious mental illness (SMI) and/or intellectual disability (ID), prior to admission to the facility) was completed accurately. This failure could have resulted in Resident 20 not receiving additional psychological services that could have assisted her in living her highest quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 21 sampled residents (Resident 96), received neurological (brain) assessments (assessment of mental status, strength, and sensation) following a fall, per the implemented care plan (a list of Resident 96's problems, goals, and interventions), and the facility policy. This failure could have resulted in a delay in identification of neurological changes prior to Resident 96's death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 45) received daily communication in Resident 45's preferred spoken language (Greek). This failure could have resulted in Resident 45's not being able to maintain or improve her ability to communicate with staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents and hazards for one of 21 sampled residents (Resident 84) when Resident 84 left cigarettes and a cigarette lighter accessible to other residents outdoors on a patio. This failure had the potential for an accidental injury to occur to other residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to monitor the use of high-risk medications (medications that pose a health risk if not monitored closely) for two out of 21 sampled residents (Resident 70 and Resident 306) when: 1. Resident 70's hold parameters (a set of numbers that guide the nursing staff to hold and not give medication for safety reasons) for use of blood pressure medication (medication use to lower pressure in arteries) were not followed. 2. Resident 306's blood sugar was not monitored while on two insulin products (insulin an injectable drug used to treat blood sugar disease or diabetes). These failed practices could put Resident 70 and Resident 306 at risk of adverse drug effects.

Inspectors wroteBased on interview and record review the facility failed to ensure the Antibiotic Stewardship Program (or ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) tracked and assessed antibiotic use based on facility policy for a resident census of 98. This failure could contribute to unsafe antibiotic use, monitoring, and increases the risk of developing resistance to germs that cause infections [when germs are not killed by an antibiotic] in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain standards of infection prevention and control for a census of 99 when the freestanding air conditioning (AC) units on each hallway contained air filters that were caked with dust and debris. This failure had the potential to spread infection to the 99 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of care were met for three out three sampled residents (Resident 1, Resident 2, and Resident 3) who sustained falls, when post fall charting (documentation of assessments and observations) was not documented for Resident 1, Resident 2 or Resident 3. This failure had the potential for Resident 1, Resident 2, and Resident 3 to have unassessed injuries, untreated pain, and/or underlying illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate and complete documentation for one of three residents sampled (Resident 2) when Resident 2 was transferred to an acute care hospital and the facility did not document the date and time of her transfer, where she transferred to, how she was transported, or the disposition of her personal effects and her medications. This failure had the potential to negatively impact resident 2's continuity of care and had the potential risk of her receiving inadequate care or services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled Residents (Resident 1) when Resident 1 did not receive her medication as prescribed, and the physician was not informed the medication was unavailable for administration. This failure had the potential to negatively impact the health and well-being of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2) when Resident 2 fell from bed while her fitted sheet was being replaced. This failure resulted in Resident 2 receiving lacerations (deep cut or tear of skin) to her left great toe, right knee, a nosebleed, and a hematoma (pooling of blood from ruptured vessels, causing a bump under the skin) to her forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 1 of 2 sampled residents (Resident 1) when; 1. Resident 1's as needed breathing treatment was not provided in a timely manner; and 2. Resident 1's oxygen concentrator (a machine used to deliver extra oxygen to a person) filter was covered in dust/debris. These failures resulted in delayed breathing treatment being provided to Resident 1 and had the potential for Resident 1's oxygen concentrator to not function as intended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food service safety were maintained for 91 of 91 residents who received food from the kitchen, when Dietary Aide (DA) 1 was preparing food for the facility while not wearing a beard net/restraint (used to prevent facial hair from falling into food). This failure had the potential to result in DA 1's facial hair to be introduced to the food being prepared resulting in physical and bacterial contamination.

Inspectors wrote2. A review of Resident 58's admission RECORD indicated Resident 58 was admitted to the facility in early 2023. During a concurrent observation and interview with LN 5 on 9/11/23, at 12:13 PM, in Resident 58's room, LN 5 confirmed Resident 58's oxygen, via nasal canula (prongs in the nose to deliver a flow of oxygen), was at 3.5 liters per minute (LPM - measure of oxygen flow rate.) During a record review of Resident 58's care plans, there was no evidence of an oxygen care plan in place for Resident 58. During an interview with the DON on 9/14/23, at 2:12 PM, the DON acknowledged Resident 58 did not have an oxygen care plan in place and confirmed there should have been an oxygen care plan in place for Resident 58. The DON explained the importance of the oxygen care plan was so that staff knew how to care for Resident 58. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care services provided met professional standards of quality for 3 of 24 sampled residents (Resident 191, Resident 12, and Resident 58), when: 1. A PICC line (peripherally inserted central catheter: a long, thin, flexible tube that is put into a vein in the upper arm to access the large veins in the chest to administer long term intravenous (IV) medications or nutrition) dressing was not changed per physician order and the PICC line site (insertion point on the body) was not monitored for Resident 191, 2. A licensed nurse (LN) signed off a PICC line dressing was changed without changing the dressing for Resident 12; and, 3. Resident 58's medical record did not reflect an accurate documentation of the medical diagnosis Bipolar disease (a mental health disease that causes extreme mood swings). [...]

Inspectors wroteBased on interview and record review the facility failed to provide restorative nursing assistant (RNA) services (interventions to increase or maintain residents' mobility and to prevent decline in mobility) for 3 of 24 sampled residents (Resident 46, Resident 48, and Resident 83) when: 1. Resident 46 had an order for RNA services three times a week beginning on 4/7/23. Resident 46's RNA documentation indicated she received services six times during the period of 8/13/23 through 9/13/23. 2. Resident 48 had an order for RNA services three times per week beginning on 5/9/23. Resident 48's RNA documentation indicated she received services two times during the period of 8/13/23 through 9/13/23. 3. Resident 83 had an order for RNA services three times per week beginning 8/27/23. Resident 83's RNA documentation indicated she received services one time during the period of 8/27/23-9/11/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services on the use of an indwelling catheter (tube which is inserted into the bladder and left in place in order to drain urine) for 1 of 24 sampled residents (Resident 193), when 1. There was no physician order for Resident 193 indicating use of an indwelling catheter, 2. There was no record of catheter care being provided to Resident 193, and 3. Resident 193's urine output was not monitored. This deficient practice had the potential for inaccurate clinical use of an indwelling catheter and had the potential to result in catheter related complications such as urinary tract infection (UTI) for Resident 193.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 2 residents (Resident 58 and 194) who received oxygen and respiratory treatment in a sample of 24 when: 1. Oxygen therapy was provided without a physician order for Resident 58, 2. Resident 194's nebulizer treatment (a small machine that turns liquid medicine into a mist) was not monitored during administration; and, 3. Resident 194's nebulizer mask was not dated and changed weekly. These failures placed Resident 58 and Resident 194 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure accountability of the delivery documents for prescription and narcotic medications (drugs with abuse potential) into the facility with a census of 91 residents. This failure had the potential for drug diversion and could contribute to unsafe medication handling.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the terms and conditions of a binding arbitration agreement (a contract between two or more parties that requires them to resolve contract disputes before an arbitrator, neutral third party rather than through the court system) were clearly explained to five of five residents (Resident 32, Resident 48, Resident 58, Resident 196 and Resident 197) whose arbitration agreements were reviewed, in a form and manner that they understood, when Resident 32, Resident 48, Resident 58, Resident 196 and Resident 197 were not informed that a binding arbitration agreement was optional and not an admission requirement, by signing it they would be giving up their right to litigation in a court proceeding, and that they had the right to rescind the arbitration agreement within 30 calendar days of signing it. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe infection control practices for 3 residents (Resident 39, Resident 15, and Resident 30) during a medication pass observation when the facility failed to clean and disinfect shared glucometers (a device used to measure the amount of sugar in the blood) in-between resident care. This failure could pose health and safety risks and cause the spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure self-administration of medication was clinically safe and appropriate for one of 13 residents observed for medication administration (Resident 13). This failure had potential to contribute to unsafe medication use by the resident and other residents including Resident 13's roommates.

Inspectors wroteBased on observation and interview the facility failed to ensure reasonable accommodation of needs were honored for 1 of 24 sampled residents (Resident 83) when Resident 83 was not provided with an appropriate call light to meet her needs. This failure resulted in Resident 83's needs to be unmet with the potential to cause physical and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to notify the local long-term care (LTC) Ombudsman (an official advocate who represents the interests of the residents residing in a LTC facility) for two of three closed record sampled residents (Resident 82 and Resident 90) who transferred out of the facility. This failure placed Resident 82 and Resident 90 at risk of not receiving the necessary protections and support of the Ombudsman.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) screening was accurate for one resident (Resident 75) in a sample of 24, when Resident 75's intellectual disability was not indicated on the PASARR. This failure had the potential for Resident 75's care and intellectual needs to be unmet due to the facility being unaware of Resident 75's intellectual disability.

Inspectors wroteBased on interview and record review, the facility failed to ensure duration of PRN (as needed medication use) psychotropic (medication used to treat mental health) medications used were clarified with a medical doctor for two out of 24 sampled residents (Resident 22 and Resident 58) when: 1. Resident 22 was prescribed PRN anxiety medication called lorazepam (or Ativan, a nerve pill) with no duration of use or re-assessment. 2. Resident 58 was prescribed PRN anxiety medication called lorazepam with no duration of use or re-assessment. These failures had the potential for unnecessary medication use without assessment resulting in a negative impact on resident's health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 91 residents. The facility had a total of four errors out of 46 opportunities which resulted in a facility wide medication error rate of 8.7 %. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. These failures had the potential to result in unsafe medications use, not following the doctor's orders, and the potential to cause complications accessing a Gastrostomy tube (or G-tube; a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices in one out of four medication carts (a mobile cart that contains medications for daily administration) when the medication cart for the South-3 station stored undated (medications with limited potency after opening per manufacturer labeling) and expired medications (medications that should not be used after its beyond use date) and the medication refrigerator at the South Station contained undated medications. These failures had the potential for residents to receive medications that were expired and/or with unsafe or reduced potency.

Inspectors wroteBased on interview and record review the facility failed to ensure professional standards of practice were followed, when the facility did not notify Resident 1's Primary Care Provider (PCP) of urinalysis (UA-checks urine for urinary tract infection) and culture and sensitivity (C&S - A culture is a test to find germs such as bacteria or a fungus that can cause an infection, and sensitivity indicates which medicine will work best to treat the infection) results received following Resident 1's discharge. This failure resulted in Resident 1 not receiving timely follow up care for a urinary tract infection (UTI).

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled resident's (Resident 1), Discharge Summary contained all the required information for continuity of care when: 1a. Information regarding Resident 1's signs and symptoms of a urinary tract infection (UTI-when bacteria cause infection in the urinary tract), a urinalysis (UA) with culture and sensitivity (C&S) was completed, and pending lab results for the UTI were not included in the Discharge Summary; and, 1b. The medication reconciliation list provided to Resident 1 was not complete. These failures resulted in Resident 1's primary care provider (PCP) and home health agency (HHA) not being aware of the need to follow up on Resident 1's signs and symptoms of a UTI, the results of the UA C&S that was done, and Resident 1 not receiving education on a medication that was prescribed to her.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident 1), in a sample of five, was free of significant medications errors when Resident 1's physician order for Liothyronine (a medication used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone), was ordered by an outside orthopedist (bone doctor) (MD) 2 and was sent electronically to and filled by the pharmacy. The facility received the medication but did not follow-up on the medication to ensure the medication was entered into Resident 1's electronic health record (EHR). This failure resulted in Resident 1 not being administered the Liothyronine from the time it was ordered on 7/24/23 until 7/31/23 when Resident 1 was discharged .