Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Gordon Health And Rehabilitation during CMS and state inspections, most recent first.
A CMA failed to properly administer insulin from a pen by withdrawing the needle immediately after injection, causing leakage, and an LPN did not identify the error during observation. In a separate event, a CMA documented potassium chloride as given on the MAR even though it was not administered, and later confirmed the medication was not actually given. The DON stated records should accurately reflect care provided and that medication administration should be documented immediately and accurately.
A medication administration review found a 12% error rate, with four errors in 33 opportunities. A CMA administering insulin to a resident withdrew the pen immediately after injection, causing leakage, and an LPN present did not identify the error. In another pass, a CMA removed and replaced a lidocaine patch but had documentation showing it was removed earlier when it was not, and potassium chloride was documented as given even though it was not administered. The DON acknowledged the observed practices were not consistent with facility expectations.
A CMA failed to use proper infection control and safe medication handling during a med pass for two residents by placing meds into her palm, touching tablets and capsules with bare fingers, and administering a dropped tablet after picking it up from the cart surface. The DON and IP stated staff are expected not to touch meds with bare hands and to discard dropped doses, and a prior grievance had already confirmed a nurse picked up a dropped med from the floor and gave it to a resident.
Medication Administration and Insulin Pen Errors
Penalty
Summary
The facility failed to maintain professional standards of practice during medication administration observations involving three medications out of 33 observed. During an 8:00 AM medication pass for a resident receiving insulin, a CMA administered 10 units of Humalog subcutaneously into the abdomen and immediately withdrew the needle, with insulin leakage observed at the injection site. The CMA then administered 45 units of Lantus and again withdrew the needle immediately without waiting the recommended 10 seconds, resulting in additional leakage. A LPN observed the administration and did not voice concerns at the time, and later stated nothing was done incorrectly before acknowledging the pen should have been held in place against the skin to prevent leakage. The CMA stated she forgot to hold the pen in place and withdrew it immediately. The facility also failed to accurately document medication administration for another resident. The MAR showed an order for potassium chloride 10 mEq every 48 hours scheduled for the 8:00 AM medication pass, and the CMA documented it as administered even though it was not given during the observation. The CMA later confirmed the medication was not administered and stated she documented it as given because the pharmacy strip package was dated for the following day and did not match the MAR. The DON stated that medical records should accurately reflect care provided, that medication administration should be documented immediately and accurately, and that discrepancies should be reported promptly to the pharmacy and licensed nursing staff.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent during a medication administration review, with four errors identified from 33 opportunities for a 12 percent medication error rate. During observation of the 8:00 AM medication pass for a resident receiving insulin, a CMA administered 10 units of Humalog subcutaneously into the abdomen and immediately withdrew the needle, with insulin leakage observed at the injection site. The CMA then administered 45 units of Lantus and again withdrew the needle immediately without waiting the manufacturer-recommended 10 seconds, resulting in additional leakage. An LPN present during the observation did not identify any concerns at the time and initially stated nothing had been done incorrectly. During another observation, a CMA removed an existing lidocaine patch from a resident’s left shoulder and applied a new patch, while stating the patch should have been removed the previous night and that removal had been documented on the MAR even though it was not removed. Review of the MAR also showed potassium chloride 10 mEq documented as administered even though it had not been given; the CMA stated she documented it as administered because the pharmacy packaged the medication in the strip for the following day and indicated the next shift would administer it without documentation. The DON stated staff are expected to follow physician orders and document medication administration accurately and timely, and acknowledged the practices observed were not consistent with facility expectations.
Improper Medication Handling During Pass
Penalty
Summary
The facility failed to ensure medications were prepared and administered using appropriate infection control practices and safe medication handling techniques for two residents, R20 and R21, during a medication pass. During observation, CMA BB opened floor stock medication containers and placed tablets and capsules into her palm before transferring them to a medication cup. While preparing medications for R21, she dropped a vitamin C tablet onto the medication cart surface, picked it up with her bare fingers, placed it into the medication cup, and administered it. During preparation for R20, she again used her bare fingers to transfer vitamin B12, Mucinex ER, senna plus, and vitamin D3 into the medication cup and administered them. In an immediate interview after the medication pass, CMA BB confirmed she touched the medications with her hands and stated she should have transferred them to the lid and then to the medication cup. She also stated that if a tablet falls, it should be discarded and replaced. The DON stated staff are taught not to touch medications with bare hands and to discard any dropped medication, but this was not specific on the competency checklist. The Infection Preventionist, who was also the ADON and an RN, stated staff are expected not to touch medications with bare hands and to discard any dropped medication, with replacement doses obtained from floor stock, the emergency box, or the pharmacy. A prior grievance documented that a nurse dropped a medication on the floor, picked it up, and administered it to a resident, and the investigation confirmed the allegation; the Social Services Director stated she did not notify the Infection Preventionist or DON and did not re-educate staff after that incident.
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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 Calhoun
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calhoun Crossing Of Journey Llc | 0.7 mi | ★★★★★ | 5 | 0 |
| Ridgewood Manor Health And Rehabilitation | 17.5 mi | ★★★★★ | 2 | 0 |
| Regency Park Health And Rehabilitation | 17.6 mi | ★★★★★ | 6 | 0 |
| Quinton Mem Hc & Rehab Center | 18.2 mi | ★★★★★ | 0 | 0 |
| Wildwood Health And Rehab | 19.1 mi | ★★★★★ | 2 | 0 |
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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.