Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lourdes-noreen Mckeen Residence For Geriatric Care during CMS and state inspections, most recent first.
Infection control failures were observed during meal service, wound care, catheter care, and blood glucose testing. A CNA did not perform hand hygiene while serving residents in the dining room, and another CNA washed hands too briefly and turned off the faucet with bare hands. EBP was not consistently implemented for residents with an open wound, indwelling urinary catheters, and MRSA-related wound care, with missing signage, missing PPE, no gown use, and glove changes without hand hygiene. An RN also failed to properly clean and disinfect a glucometer after use.
Dignified Care and Respect Failures: Two residents experienced failures in dignified care and communication. One resident with moderate cognitive impairment reported delayed toileting assistance, being told to use his diaper, and staff speaking another language in front of him while on their phones; during a sponge bath, a private aide used shampoo instead of the available soap to wash the resident’s face and body. Another cognitively intact resident reported that most CNAs were rude, not compassionate, and slow to answer call lights, often saying they would return soon but not coming back for 45 minutes.
A facility failed to honor resident choice for bathing for two residents. One resident with dementia and extensive bathing assistance needs was repeatedly observed with greasy, unwashed hair while staff relied on an overnight shower schedule and did not track whether hair washing occurred. Another resident with moderate cognitive impairment and MRSA was told by staff and the DON that he could not use the wheelchair-accessible shower in his room, despite the bathroom being equipped with grab bars and a handheld shower head.
A resident with moderate cognitive impairment had a signed DNR order in the chart, but the active physician orders listed Full Code. The care plan and quarterly meeting note documented that advance directives were reviewed with the resident’s representatives and that DNR and POA were on file, yet the code status was not changed back from Full Code to DNR as expected.
Failure to supervise residents during mealtime: A resident with moderate cognitive impairment, dysphagia, and malnutrition was observed alone in the dining room coughing nonstop while an LPN stayed at the med cart and did not assess the resident; the resident’s care plan and SLP eval called for total assist, close supervision with oral intake, and no straws. In another dining room, residents were served by CNAs and a dietary aide with no nurse observed during one lunch period, and an RN later said the unit nurses rotate and cover for each other.
Failure to provide wound care and services according to orders for a resident with a forehead wound. The resident was repeatedly observed with a bandage on the forehead that had no date or initials, while the chart had no treatment order or documentation for the dressing. An LPN said staff kept applying the bandage even though the resident did not need it, and the supervisor later found the wound open with wet, white exposed tissue and drainage on the dressing.
Failure to provide ordered nutritional supplements: A resident with severe cognitive impairment had physician orders for a Magic Cup and a Mighty Shake every meal for nutritional support, but multiple observed meal trays lacked the ordered supplements. The spouse reported the resident sometimes received supplements and sometimes did not, and the RD confirmed the trays should have included both ordered items.
A resident with moderate cognitive impairment and swallowing difficulty had a physician order for Jevity 1.5 via feeding tube at 70 ml/hr for 20 hours, but observations showed the tube feeding repeatedly running at 60 ml/hr instead. One observation showed the container had been started at the lower rate and only part of the ordered nutrition had been delivered, and the record lacked a documented reason for the slower rate or incomplete administration. An RN confirmed she continued the previous programmed rate without checking it, and the RD stated she had not recently checked the administration rate.
Oxygen tubing and filter care was not maintained for multiple residents. A resident with COPD and acute respiratory failure had oxygen set at a higher rate than ordered, with tubing not dated and a dusty filter, while another resident with Parkinson’s disease, dysphagia, and pneumonitis had tubing left uncovered or on top of the O2 machine, not bagged or dated, and a dirty filter. An RN stated tubing and filters are handled on the Sunday night shift and that whoever changes the tubing is supposed to label it.
Expired meds were found in a medication cart and med room on one unit, and an LPN agreed they should have been removed from inventory. On another unit, a narcotic count for a resident’s oxycodone/APAP did not match the controlled med record, and two LPNs gave conflicting accounts of the waste and disposal location, with no signature documenting the waste.
Medication errors exceeded the allowed rate, with two residents involved in missed, delayed, and incorrect medication administration. An LPN did not give ordered meds because they were not available, placed meds on a bedside table without a barrier, and documented a topical cream as given even though the tube was unopened; later, an RN administered 5 units of Humulin N when the MAR ordered 6 units.
A resident with moderate cognitive impairment and Lewy body dementia had a prescription topical medication left on the nightstand on multiple observations, despite no documented self-administration assessment. The resident said the nurse applied the medication, while an LPN confirmed there was no current order for a scalp prescription and later removed the bottle from the bedside after speaking with the spouse.
Food Preferences Not Honored: A cognitively intact resident on a regular diet reported requesting poached eggs after seeing them on the menu, but staff would not provide them. The menu on the unit still listed poached eggs, though crossed off in red, and staff gave conflicting explanations for why the item was unavailable, including salmonella concerns, an egg shortage, and outdated dietary menus still being used.
Failure to provide ordered thickened liquids for two residents with dysphagia. One resident with a physician order for honey-thick liquids was observed with straws and unthickened Ensure was reported by the family, while another resident ordered nectar-thick liquids was observed in the dining room with a straw and coughing profusely as an LPN did not assess the resident. Speech therapy had recommended close supervision and no straws for both residents.
The facility failed to ensure the accessibility of call lights for three residents, leading to deficiencies in accommodating their needs. One resident's call light was tied around the side rail, another's was on the floor, and a third's was wrapped around an enabler bar, making them all inaccessible.
A resident was found to have multiple medications in an unlocked nightstand drawer and on top of the nightstand without an assessment for self-administration or a physician's order. The resident admitted to using these medications, and the DON confirmed that residents are not supposed to have medications at the bedside without proper assessment and orders.
The facility failed to administer medications timely for a resident with Parkinson's Disease and Orthostatic Hypotension. Medications were frequently given outside the prescribed time window, affecting the resident's ability to eat on time and feed herself. The Consultant Pharmacist confirmed the issue, and the Director of Nursing acknowledged the problem.
Infection control failures during dining, wound care, catheter care, and glucometer use
Penalty
Summary
The facility failed to implement infection control processes during a lunch meal observation in the 2S dining room. A CNA wheeled a resident into the dining room and, without performing hand hygiene, passed out silverware, poured drinks, and continued assisting multiple residents. The CNA also touched residents while moving through the dining room. During the same observation, another CNA washed her hands at the sink after being spoken to by an RN, but did so very quickly and turned off the faucet with bare hands instead of using a paper towel. The RN stated staff should be doing hand hygiene between tables, and the Infection Control Preventionist later stated more education was needed. The facility also failed to implement Enhanced Barrier Precautions for a resident with an open stage 3 pressure ulcer. The resident had a wound care order and was cognitively intact, but the record lacked an EBP order and the care plan lacked documentation for EBP. Observations showed no EBP sign or PPE at the resident’s room. During wound care, the RN brought supplies to the common shower area, performed wound care there, changed gloves without hand hygiene, and did not wear a gown. The resident stated staff usually did wound care in the shower room and did not wear gowns. The RN later stated a gown should be used during direct care and wound care, but had no reason for not wearing one during the observation. The facility further failed to implement EBP for residents with indwelling urinary catheters and a resident with a wound and MRSA history. One resident with a urinary catheter had no EBP sign or PPE at the room during multiple observations, and the record lacked EBP orders before the survey. Another resident with a Foley catheter also had no EBP signage at the door during several observations, despite an order for EBP related to the catheter. A resident with a back wound and MRSA had an order for EBP, but observations showed no sign or supplies at the door, and during wound care an LPN did not wear a gown and did not change gloves after cleaning the wound. In addition, the facility failed to disinfect a glucometer after use for a resident’s blood glucose check; the RN used the glucometer, returned to the cart, and then quickly wiped it with one alcohol wipe instead of cleaning and disinfecting it per policy.
Dignified Care and Respect Failures
Penalty
Summary
The facility failed to render dignified care and services for Resident #31, who had a BIMS score of 11 indicating moderate cognitive impairment and required substantial to maximum assistance with toileting and bathing. The resident stated that on the evening shift he could wait two hours for help to the bathroom, that weekends were worse, and that staff had told him to just go in his diaper, which he said was an insult to his dignity. He also reported that aides were on their phones while caring for him and spoke another language in front of him, making him feel unsure whether they were talking about him. During morning care, the resident’s private aide used Head & Shoulders shampoo on a washcloth to wash the resident’s face, back, groin, and bottom during a sponge bath, despite a bar of soap being present next to the shampoo and additional supplies available in a bin under the sink. The resident stated it was better than nothing and noted that his regular aide knew where everything was and what to use. The LPN assigned to the resident confirmed the shampoo and soap were in the room and stated she remained responsible for the resident’s care even when provided by a private aide. The facility also failed to ensure dignified interactions for Resident #41, who was cognitively intact and reported that most CNAs were rude, not compassionate, and irritating, and that call lights were not answered timely. The resident said staff repeatedly told her they would return in 5 minutes or be right back, but often did not return for 45 minutes; a prior grievance documented similar concerns about rude staff and untimely call light response.
Failure to Honor Resident Choice for Bathing and Shower Access
Penalty
Summary
The facility failed to honor resident choice and self-determination for two sampled residents related to bathing and showering. Resident #12 had diagnoses including unspecified dementia, hemiplegia, and repeated falls, and an MDS assessment documented severe cognitive impairment with a BIMS score of 7. Her care plan stated she required extensive assistance with bathing and showering, and her daughter requested that her hair be washed on shower days. However, the daughter reported that staff said the resident refused hair washing in the shower, which did not match her experience with the resident having her hair washed in the salon and not refusing there. Observations showed Resident #12 repeatedly with hair that appeared flat, greasy, limp, and oily while in bed, at the nurse’s station, and in the dining room. Staff stated she was on an 11 PM to 7 AM shower schedule on Monday, Wednesday, and Friday, but also stated that if the resident refused when approached around 5:00 to 6:00 AM, staff would not give the shower. Another RN stated that if the scheduled shower time did not work, the schedule would need to be changed, and if a resident on the overnight schedule refused daily, the resident would get a full bed bath that includes hair washing. The showering/bathing task record showed no showers during the prior 30 days and only bed baths were checked, with no category to track whether hair was washed. Resident #97 had moderate cognitive impairment and a wound culture showing MRSA to a wound on his back. His sister stated she wanted to know why he could not use the shower in his room, and she reported that the DON and an LPN told her he was not allowed to use it. The bathroom in his room was observed to have a wheelchair-accessible shower with grab bars and a handheld shower head, but no shower chair was present. The resident stated staff had never given him a shower in his room. The DON initially said she did not recall speaking to the sister, then stated the shower might not be big enough or safe, but after seeing a picture of the bathroom she said she did not see why he could not use it.
Code Status Not Updated to Match DNR Wishes
Penalty
Summary
The facility failed to ensure the desired code status was in place for one resident reviewed for advance directives. The resident was admitted and later readmitted to the facility, and the MDS assessment showed a BIMS score of 8, indicating moderate cognitive impairment. The record contained a signed DNR order in the scanned documents, but the current physician orders listed the resident as Full Code. The active care plan documented that the resident had an advance directive, with goals and interventions to discuss and review DNR status with the resident and/or representative, inform them that advance directives could be changed or revoked, and ensure staff were aware of the resident’s wishes. The quarterly care plan meeting note documented that the interdisciplinary team spoke with the resident’s representatives by telephone and reviewed advance directives, with no changes and DNR and POA on file. During interview, the Social Services Director stated that a telephone order for Full Code had been entered into the EMR by the admitting nurse based on the hospital preliminary history and physical report, but that by the time of the care plan meeting the code status should have been changed from Full Code back to DNR. The Social Services Director also stated that it was her responsibility, and explained that when rescinding a DNR, the word RESCIND would be written in large letters across the top of the DNR form.
Failure to Supervise Residents During Mealtime
Penalty
Summary
The facility failed to provide dining services and supervision for a resident with moderate cognitive impairment, dysphagia, and malnutrition who required total assistance with activities of daily living and meals. On observation in the 4North dining room, the resident was seated alone with a sippy cup containing a thickened red drink and a straw, and was coughing profusely nonstop while an LPN remained at the medication cart across from the dining room and did not go in to assess the resident. The LPN stated she was familiar with the resident and that the resident normally coughs that way, and she continued preparing medication instead of checking on the resident. A CNA later entered the dining room to assist the resident, who was still coughing. The care plan documented the resident needed total assistance and staff monitoring of food and fluid intake, and the speech evaluation recommended close supervision with oral intake and no straws due to aspiration risk. During lunch service in the 2S dining room, residents were observed being brought in and served by CNAs and a dietary aide, but no nurse was observed in the dining room during the meal period on one observation. On later observations, an RN was seen sitting at the back table observing residents and working on her laptop. When interviewed, the RN stated the unit nurses rotate and cover for each other, and she was unsure why she was not in the dining room on one of the observed days. When told there were only three aides in the dining room that day, she had no explanation.
Failure to Provide Ordered Wound Care for Forehead Wound
Penalty
Summary
The facility failed to provide wound care and services according to orders for one resident with a wound to the forehead. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was observed over several days with a white square bandage on the forehead that had no date or initials written on it. The resident stated the bandage was changed when he showered and described the injury as something that happened when he banged his head, possibly in the shower, while another account later given to staff was that he bumped into a wall. Review of the incident log did not show documentation of a wound-related incident, and weekly skin assessments documented no observed skin issues. During interviews, an LPN stated the resident did not need the bandage and that nurses were putting it on because he had a biopsy done a while ago, despite no treatment order being present. The ADON reviewed the record and found no documentation for the bandage or wound care, and the supervisor stated she did not know anything about the bandage and that if something had happened there would have been an incident report. When the supervisor removed the dressing, the forehead wound was open, the exposed skin was wet and white, and there was a small amount of tan and red drainage on the bandage.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure that Resident #133 received nutritional supplements as ordered by the physician. The resident was admitted to the facility and had a current MDS assessment showing a BIMS score of 6, indicating severe cognitive impairment. The physician orders, written in response to the RD's assessed needs and recommendations, directed that the resident receive both a Magic Cup and a Mighty Shake every meal for nutritional support. During observations, the resident's meal trays did not include the ordered supplements. On 09/02/25, the lunch tray delivered to the resident in his room lacked both the Magic Cup and the Mighty Shake, even though the resident had eaten the food on the tray and was being fed by his wife. On 09/04/25, the breakfast tray at bedside also had no nutritional supplement. Later that day, the spouse stated that the resident sometimes received nutritional supplements and other times did not, and another lunch tray observed at that time again lacked any nutritional supplement. The RD confirmed that the tray should have contained both ordered supplements and stated she needed to do some education after reviewing the photos.
Feeding Tube Administered at Incorrect Rate
Penalty
Summary
Resident #102, who had moderate cognitive impairment with a BIMS score of 9 and documented coughing and swallowing difficulties while eating, received nutrition through a feeding tube under a physician order for Jevity 1.5 Calorie at 70 ml per hour for 20 hours. The order specified the feeding was to start at 1 PM and stop at 9 AM the following day to provide 1400 ml of nutrition. Review of the record and observations showed the tube feeding was repeatedly running at 60 ml per hour instead of the ordered 70 ml per hour, including when the resident was away from the room and on later observations when the feeding was still set at 60 ml per hour. On one observation, the Jevity container label showed the feeding had started at 1 PM the prior day at 60 ml per hour, and there was approximately 225 ml left in the container, indicating the resident had received only 775 ml of the ordered 1400 ml during that period. The record did not contain a documented reason for the slower rate or for not completing the feeding as ordered. During interview, the RN confirmed the physician order was for 70 ml per hour and stated she had continued the previous programmed rate without checking it, and the RD stated the current rate was 70 ml per hour but had not recently checked the administration rate for this resident.
Oxygen tubing and filter care not maintained
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure oxygen care and services for 3 of 4 sampled residents. The facility’s policy titled, Oxygen Safety-Nursing Service, dated 04/21/23, did not include a policy on the frequency of changing and dating oxygen tubing or the procedure for cleaning the oxygen filter. For Resident #6, who was admitted with diagnoses including Cerebral Infarction, Acute Respiratory Failure with Hypoxia, and COPD, physician orders dated 04/02/25 directed oxygen at 2 liters via nasal cannula continuously every shift and to change, label, and bag all tubing and masks, wipe down the concentrator and nebulizer machine, and change the concentrator filter every Sunday night shift. During an interview and observation on 09/03/25 at 9:39 AM, Resident #6 stated her oxygen order was for 2 liters and to use oxygen as needed, while the oxygen rate was set at 5 liters, the tubing was not labeled with a date, and the filter was full of dust. Resident #9, admitted with diagnoses including Parkinson’s Disease without Dyskinesia, Pneumonitis due to inhalation of food and vomit, and Dysphagia, had physician orders for oxygen 2 liters per minute via nasal cannula as needed and to change, label, bag all tubing and masks, wipe down the concentrator and nebulizer machine, and change the concentrator filter every Sunday night shift. Observations on 09/03/25, 09/04/25, and 09/05/25 showed the oxygen tubing on the floor uncovered or wrapped on top of the oxygen machine, not in a bag, not dated, and the filter dirty. Staff E, RN, stated that oxygen tubing and filters are replaced or cleaned by nurses on the Sunday night shift and that whoever changes the tubing is supposed to label it.
Expired Medication Left in Cart and Room; Narcotic Count Discrepancy Not Documented
Penalty
Summary
The facility failed to remove expired medication inventory from a medication cart and medication room on the 4N unit, and expired resident-specific and stock medications were observed during a surveyor review with an LPN. The LPN agreed the medications were expired and should have been removed from inventory. The expired stock inventory was collected by Central Supply later that day, and the LPN stated the night nurse was responsible for completing the log form so expired resident-specific medication could be collected. The facility also failed to ensure narcotic reconciliation on the 2S unit for Resident #136. During review of the controlled medication record and the locked narcotic box, the count for oxycodone/APAP 5-325 mg did not match: the packet contained 6 pills while the record showed 7 remaining. An LPN stated she and the nurse she relieved wasted one pill because it was falling out of the packet, but there was no signature on the narcotic reconciliation form documenting the waste. When questioned separately, the two nurses gave conflicting accounts of where the narcotic was disposed of, with one stating it was placed in the pill buster and the other stating it was thrown in the trash can by the medication cart.
Medication Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure it was free of medication errors, with a medication error rate of 15.38% based on 26 opportunities, involving two sampled residents. For one resident, an LPN was observed administering medications and stated she did not have Mag Ox or Calcium for the resident and would not give them. The resident’s physician orders included Mag Ox 400 mg twice daily for hypomagnesemia and Calcium +D 500-10 mg daily for hypocalcemia. The LPN later stated she had to order the medications from the pharmacy and could order them directly from her computer. During the same medication pass, the LPN placed the medication cup and inhaler on the resident’s bedside table without a barrier before the resident took the medications and self-administered the inhaler. For the second resident, an LPN was observed preparing medications and placed the medication cup on the bedside table without a barrier and did not wash her hands before administering the medications. The resident had an order for Alclometasone Dipropionate Cream 0.05% twice daily for dry skin, but the LPN stated she had not yet administered the cream, and the tube was unopened and dated with the original order date. The July and August 2025 TAR documented that the cream had been administered. Later, an RN prepared Humulin N insulin for the same resident and stated she was giving 5 units because the blood sugar was 205. After administering the insulin, she reviewed the MAR and stated the order actually called for 6 units, saying it looked like a 5.
Medication Left at Bedside Without Proper Storage
Penalty
Summary
The facility failed to store medication properly for 1 of 29 sampled residents when a prescription medication was left at the bedside of a resident with moderate cognitive impairment. Resident #32 was admitted to the facility and had a quarterly comprehensive assessment documenting a BIMS score of 10, indicating moderate cognitive impairment. The resident’s care plan identified an activities of daily living self-care deficit related to Lewy body dementia, and the record did not show an assessment for self-administration of medication. Observations on multiple occasions showed a bottle of prescription medication on the resident’s nightstand, including a prescription topical medication and later a bottle of triamcinolone cream. During interview, the resident stated the medication was for the head and that the nurse applied it. Staff reviewed the resident’s orders and stated there was no order for a prescription medication to be applied to the scalp, only CeraVe lotion. In a phone conversation, the resident’s spouse stated the medication had been there since the beginning of the resident’s stay, and staff stated the dermatologist had not seen anything on the scalp. The medication was then removed from the bedside.
Food Preferences Not Honored
Penalty
Summary
The facility failed to ensure food was provided according to resident preference for one resident who was cognitively intact with a BIMS score of 14 and ordered a regular diet. The resident stated she had asked for poached eggs and was told they would not make them, even though she had seen them on the menu. During breakfast observation, the resident again requested poached eggs but accepted another choice after being shown the menu by staff. The menu shown to the resident on the unit still listed poached eggs, but the item had been crossed off in red. A Dietary Aide stated poached eggs had been removed because of salmonella concerns in the news and said hard boiled eggs were available every other day. The resident stated she had not been informed why poached eggs were crossed off and had never had the option of poached eggs since admission. The Food and Beverage Director stated poached eggs had been taken off the menu in February 2025 because of an egg shortage and inability to obtain pasteurized eggs, and acknowledged the unit was still using outdated dietary extensions and a menu that included poached eggs.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for 2 of 2 sampled residents with dysphagia. Resident #38 had a physician order for a regular diet with pureed texture and honey-thickened liquids, and the speech evaluation dated 08/19/25 recommended close supervision with oral intake and no use of straws because the resident was at risk for aspiration, dehydration, and malnutrition. During observation on 09/02/25, Resident #38 was found with a packet of thickener, a cup of light yellow liquid, and other cups with straws on the bedside table, and on 09/03/25 a cup with a straw was again observed on the bedside table. The resident’s daughter told the DON and ADON that staff had given the resident Ensure without adding thickener and that he was coughing heavily. Resident #50 had a physician order for a regular diet with pureed texture and nectar-thick liquids, and the care plan identified risk for inadequate nutrition and hydration related to poor appetite, protein calorie malnutrition, and dysphagia. During observation in the dining room on 09/03/25, Resident #50 was sitting alone with a cup of thickened red liquid and a straw, and was coughing profusely nonstop while an LPN remained at the medication cart and did not go to assess the resident. The speech evaluation dated 05/12/25 recommended close supervision with oral intake and no use of straws because the resident was at risk for aspiration.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure the accessibility of call lights for three residents, leading to deficiencies in accommodating their needs. Resident #56, who had mild cognitive impairment and multiple diagnoses, was found unable to reach his call light, which was observed to be tied around the side rail and not plugged into the wall. His son confirmed that this was a recurring issue. Resident #101, who was cognitively intact but suffering from severe pain in his right arm due to cellulitis, was also unable to reach his call light, which was found on the floor next to his bed. He confirmed that he had not been able to get out of bed or reach the call light due to his condition. Resident #71, who had a cognitive response and multiple diagnoses including Parkinson's Disease, was observed with her call light wrapped around the enabler bar, making it inaccessible. A staff member admitted that the call light was likely placed there during breakfast service. Interviews with other staff members revealed that call lights are supposed to be placed on the bed within reach of residents, and wrapping them around bed rails is against policy. Despite this, the call lights were not consistently accessible to the residents, leading to a failure in meeting their needs and preferences.
Failure to Safely Store Medications
Penalty
Summary
The facility failed to safely store medications for a resident who was found to have multiple medications in an unlocked nightstand drawer and on top of the nightstand. The resident had no assessment for self-administration of medications and no physician's order to self-administer any medications. Observations revealed that the resident's nightstand contained Systane lubricant eye drops, probiotics, organic cranberry supplements, urinary harmony supplement capsules, and Fluorouracil topical cream. The resident admitted to using these medications and supplements, and the Director of Nursing confirmed that residents are not supposed to have medications at the bedside without proper assessment and orders. The resident was admitted with diagnoses including Heart Failure, Vitamin Deficiency, Dry Eye Syndrome, Candidal Stomatitis, and a personal history of urinary tract infections. Despite the facility's policy requiring a written order and assessment for self-administration, these steps were not followed. The Director of Nursing acknowledged the oversight when shown photographic evidence of the medications at the bedside and stated that the issue would be addressed.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure timely administration of medications for Resident #71, who had diagnoses including Encephalopathy, Parkinson's Disease, and Need for Assistance with Personal Care. The resident's physician had ordered Carbidopa-Levodopa to be administered three times a day at 9:00 AM, 1:00 PM, and 5:00 PM, and Droxidopa to be administered at the same times. However, the Medication Administration History Report revealed that these medications were frequently given outside the prescribed time window. Specifically, Carbidopa-Levodopa was administered outside the 60-minute window on 7 out of 21 opportunities, and Droxidopa was administered outside the window on 9 out of 21 opportunities, with some doses given too close together or too late in the day, potentially affecting the resident's condition and daily activities. Interviews with Resident #71 and her daughter indicated that the late administration of Parkinson's medication affected the resident's ability to eat on time and feed herself. The Consultant Pharmacist (CP) confirmed that the medications were not administered as ordered and acknowledged that Carbidopa-Levodopa should ideally have 3 to 4 hours between doses to avoid agitation. The CP also noted that Droxidopa should not be administered close to bedtime to prevent orthostatic hypotension. The CP suggested that staff should document reasons for any deviations from the scheduled times in the nurse's notes. The Director of Nursing (DON) acknowledged the issue and stated that she had just become aware of the problem. The report highlights that the facility's failure to administer medications within the prescribed time frames led to potential negative impacts on Resident #71's health and daily functioning. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, but this was not consistently followed for Resident #71's medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of West Palm Beach | 1.9 mi | ★★★★★ | 4 | 0 |
| Lakeside Health Center | 2 mi | ★★★★★ | 2 | 0 |
| Darcy Hall Of Life Care | 2.8 mi | ★★★★★ | 4 | 2 |
| Colonial Skilled Nursing Facility Llc | 2.9 mi | ★★★★★ | 0 | 0 |
| Westgate Health And Rehabilitation Center | 3.1 mi | ★★★★★ | 1 | 0 |
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