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 Bethany Woods Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that a medication cart on one hall was left unlocked and unattended with the narcotic drawer open and medications, including liquid Morphine, Fluoxetine, and Gabapentin, left on top of the cart while the assigned nurse was in a resident’s room. On another hall, surveyors observed an unlabeled Ozempic pen in use, a Lantus Solostar insulin pen not in use but stored in the cart instead of refrigerated, latanoprost eye drops kept beyond the labeled six-week post-opening period, and several opened stock medications (geritussin, guaifenesin, milk of magnesia) without dates indicating when they were opened. A medication aide, a unit manager, and the DON acknowledged that medications should be secured, labeled with resident identifiers and open dates, stored per manufacturer directions, and discarded when expired.
A nurse was stopped by law enforcement and found with multiple non‑narcotic prescription medications, including gabapentin, carvedilol, antidepressants, antiepileptics, antibiotics, antiemetics, inhalers, and other drugs, packaged in single‑dose packs and multi‑dose cards labeled for numerous residents. The nurse stated she had taken the medications from her workplace and forgotten to return them. Facility review confirmed the medications belonged to multiple residents and some unknown residents, and that they had been removed from medication carts or storage without authorization, including medications for residents the nurse had not been assigned to. The facility could not determine how or when the medications were taken and only became aware of the diversion after notification from law enforcement, demonstrating a failure to safeguard resident medications from misappropriation.
A cognitively intact resident with mood and anxiety disorders, whose care plan called for staff to avoid arguments due to his history of verbal aggression, overheard two NAs discussing another employee in the hallway and yelled out his disagreement using profanity. One NA responded and engaged in a verbal exchange with the resident from the hallway, during which both used profanity. Interviews with the resident, a witnessing NA, the DON, and the Administrator confirmed that the staff member argued with the resident and used inappropriate language in his presence, failing to maintain the resident’s dignity and respect.
A quadriplegic, cognitively intact resident who was dependent for all ADLs and used a mouth‑blowing call device to summon help was repeatedly observed in bed with the device positioned out of reach, despite the care plan and Kardex specifying its use. On multiple occasions, staff either did not notice or could not recall checking the device’s placement after providing care, and the resident reported having to yell out or use a voice‑activated phone to request assistance when the device was not accessible. Nursing staff acknowledged the device needed to be close to the resident’s mouth to function, and the DON stated the expectation that it always be within reach, while also noting the resident could call out or use a cell phone to communicate needs.
A resident with chronic respiratory failure and COPD had a physician order and care plan for continuous oxygen at 3 LPM via nasal cannula, but surveyor observations on two days found the concentrator set at 2.5 LPM when read at eye level. The resident, who was cognitively intact, reported she was supposed to receive 3 LPM and was not in visible respiratory distress. A medication aide had documented on the MAR that the oxygen was set at 3 LPM, but she demonstrated that she read and adjusted the concentrator while standing over it rather than at eye level, leading to inaccurate verification of the flow rate. The Unit Manager had not checked this resident’s oxygen settings on those days, while the Medical Director and DON stated the expectation that the ordered 3 LPM be provided.
Surveyors identified that the facility exceeded the acceptable medication error rate when a nurse withheld a prescribed dose of metoprolol for a resident with cardiac conditions despite vital signs not meeting the physician-ordered hold parameters, and did so without obtaining a concurrent physician order. In a separate instance, the same nurse allowed a resident with COPD to self-administer fluticasone nasal spray without instruction, resulting in the resident rapidly delivering three sprays into each nostril instead of the ordered two sprays per nostril, and the nurse did not correct the technique or dosage.
A resident with a right BKA, diabetes, CHF, and PVD, who was cognitively intact, frequently incontinent, and dependent for ADLs, was photographed while receiving bowel incontinence care, with his buttocks uncovered and feces visible on the bed. An NA reported answering repeated personal calls on her cellphone via FaceTime while in the resident’s room and stated that the device must have captured an image of the resident’s exposed backside as she was locking and pocketing the phone. The DON and Administrator received an anonymous report and a copy of the image, then identified the resident based on the visible amputation, clothing, and room features, confirming that the resident’s personal privacy was not maintained during care.
The facility failed to accurately post daily nurse staffing information, with numerous discrepancies between the posted sheets and the internal schedules for RNs, LPNs, MAs, and NAs across multiple shifts. Posted staffing counts often showed higher or lower numbers of staff than were actually scheduled, and in some cases listed staff categories that were not scheduled at all. The staff member responsible for scheduling and postings acknowledged that the postings were not updated when staff called out, did not show, or came in to cover, and leadership confirmed that the postings were expected to match actual staffing but did not.
Surveyors found that multiple resident rooms were not maintained in good repair or in a clean, homelike condition, including walls with exposed sheetrock and recurring scrape marks behind and beside beds, a large unsanded and unpainted wall patch, a loose vinyl baseboard exposing bare wall under a sink, and a PTAC unit with visible dust buildup inside its vents. The Maintenance Director, who had recently assumed the role and was the only maintenance staff member, acknowledged being behind on room repairs and PTAC cleaning and reported that bed and wheelchair movement contributed to repeated wall damage, while the Administrator acknowledged that rooms should be kept in good repair and homelike.
The facility failed to provide routine hair trimming services for four residents who were unable to perform this activity themselves. Despite residents expressing dissatisfaction with their hair length, staff interviews revealed a lack of awareness and responsibility for providing haircuts. The facility had not arranged for haircuts outside the facility, and transportation for non-medical appointments was unavailable.
Two residents received incorrect medications due to a new nurse's errors in a LTC facility. The nurse, lacking adequate training and supervision, administered medications prescribed for other residents. The errors were discovered after administration, and the residents were monitored for adverse effects. The facility acknowledged the errors, and the nurse is no longer employed there.
Two residents in an LTC facility were affected by medication errors. One resident received another's medications, including fish oil and famotidine, due to a nurse's mistake. Another resident with anxiety did not receive a morning dose of Ativan and later received a double dose due to errors in medication administration. Both incidents were reported, and no harm was reported for either resident.
Failure to Secure Medication Carts and Properly Store and Label Medications
Penalty
Summary
Surveyors identified that medications and controlled substances were not consistently secured and stored according to professional standards. On the 400 hall, an unattended medication cart was observed over a three-minute period with the lock mechanism in the unlocked position, indicated by a visible red dot, and the narcotic drawer pulled open with medications exposed. On top of the cart, there was a cup containing crushed white pills and a small white bottle with red liquid medication. No residents, staff, or visitors were present near the cart during this time. The nurse assigned to the 400 hall cart acknowledged she had stepped into a resident’s room and forgot to close the narcotic drawer, secure the medications on top of the cart, and lock the cart, and verified that the medications left out included liquid Morphine, Fluoxetine, and Gabapentin. The DON confirmed that medications should not be left unattended and that medication carts should be secured. On the 800 hall, surveyors observed multiple medication storage and labeling issues in the medication cart in the presence of a medication aide. An Ozempic pen in use was found open and unlabeled, a Lantus Solostar insulin pen not in use was stored in the cart instead of being refrigerated as directed on the label, and a bottle of latanoprost eye drops opened and dated 2/4/26 remained in the cart beyond the labeled six-week post-opening expiration period. Additionally, opened bottles of geritussin, guaifenesin liquid, and milk of magnesia were present without dates indicating when they were opened. The medication aide stated she was unaware the Ozempic pen was unlabeled, acknowledged that the Lantus pen should have been refrigerated if not in use and that the eye drops should have been discarded per label instructions, and indicated that stock medications should have been labeled with the date opened. The unit manager and DON both stated that staff assigned to the cart should check labels for resident identifiers, open and expiration dates, and that insulin pens and other medications should be labeled and stored per directions.
Misappropriation of Resident Medications by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their medications when a nurse was found in possession of multiple prescribed, non‑narcotic medications belonging to residents. Law enforcement conducted a traffic stop of Nurse #1 due to a vehicle registration infraction and, during a search prompted by the smell of marijuana, discovered multiple prescription medications in a bag and under the passenger seat. Nurse #1 told law enforcement she had obtained the medications from the facility where she worked, had placed them in her pocket, and forgot to return them. The police detective overseeing the narcotics division and special operations confirmed that multiple single‑dose packs and medication cards were found in the vehicle, that Nurse #1 identified herself as a nurse, and that no narcotic medications were involved. The facility’s own investigation, initiated after notification from law enforcement, identified that the medications in Nurse #1’s possession belonged to 16 residents and also included several medications that could not be matched to a specific resident. The medications included gabapentin, carvedilol, paroxetine, carbamazepine, meloxicam, Xifaxan, Zofran, trazodone, simethicone, lisinopril, divalproex, vitamin B12, paliperidone, Levaquin, prednisone, guaifenesin, sertraline, Xarelto, albuterol inhalers, Prilosec, Voltaren gel, Phenergan, benzonatate, and an additional inhaler and Zofran card belonging to unknown residents. These medications were found in multi‑dose medication cards, single‑dose smart packs, inhalers, and topical preparations, all of which were identified as resident‑specific medications that should have remained under facility control. The medications were retained by law enforcement as evidence and were not returned to the facility. Record review showed that Nurse #1 had been employed at the facility during two separate periods and had been terminated both times for poor attendance. She had received training on the facility’s abuse, neglect, misappropriation, and exploitation policy at the start of each employment period. The facility’s investigation determined that, although medication administration records and assessments did not show missed doses or adverse outcomes for the residents, the manner and timing of the removal of the medications from the facility could not be determined. It was noted that some of the medications may have been discontinued or belonged to residents no longer in the facility, and that some medications might have remained on the medication carts or in the medication room awaiting return to the pharmacy. The facility substantiated that Nurse #1 had been found in possession of resident medications without authorization and acknowledged that it had no prior knowledge of the unauthorized removal until notified by law enforcement. Interviews with the prior Administrator, the DON, the Medical Director, and the pharmacy consultant confirmed the sequence of events and the scope of the misappropriation. The prior Administrator and DON described going to the police station to inventory the medications and working with the pharmacy to identify the residents and medications involved. The Medical Director and nurse practitioner were aware of each resident who could have been affected and reviewed their status, and the pharmacy consultant verified that she assisted in identifying when the medications had been dispensed. Despite these efforts, the facility was unable to determine exactly how or when Nurse #1 removed the medications, including some that were associated with residents she had not been assigned to care for. The Administrator later stated that efforts were still ongoing to prevent misappropriation of resident medications and that the State Agency found the facility’s submitted plan of correction unacceptable because it did not include a systemic approach to prevent future misappropriation of resident property. The facility’s written policy on abuse, neglect, misappropriation, and exploitation, dated August 2019, stated that residents have the right to be free from misappropriation of resident property and defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without consent. The presence of multiple resident‑specific medications in Nurse #1’s personal vehicle, outside the facility’s control and without resident consent, constituted misappropriation of resident property. The facility’s inability to account for how these medications were removed from secure storage, including medications for residents not under Nurse #1’s direct care and medications that should have been returned to the pharmacy, demonstrated a failure to adequately safeguard residents’ medications from wrongful use or removal. The investigation also documented that the facility became aware of the incident only after being contacted by local law enforcement, rather than through its own internal controls or monitoring systems. The facility’s records and interviews did not reveal any prior reports or observations of unauthorized medication removal by Nurse #1 before the traffic stop. The fact that multiple medications from multiple residents, including discontinued or unassigned medications, were found in Nurse #1’s possession indicates that the facility’s systems for tracking, securing, and disposing of resident medications were insufficient to prevent or detect misappropriation. This failure resulted in resident medications being wrongfully removed from the facility and placed under the control of an individual staff member outside the facility environment, contrary to the residents’ rights and the facility’s own policy. The deficiency therefore centers on the facility’s failure to protect residents from misappropriation of their medications, as evidenced by a nurse’s possession of multiple resident‑specific medications outside the facility, the lack of internal detection of the diversion, and the inability to determine when and how the medications were removed. The facility’s own investigation substantiated that misappropriation occurred and confirmed that the medications belonged to identified residents and to unknown residents, demonstrating that resident property was wrongfully used and removed without consent.
Failure to Maintain Resident Dignity During Verbal Exchange With Staff
Penalty
Summary
The deficiency involves a failure to ensure that a resident was treated in a dignified and respectful manner, as required by resident rights. A cognitively intact resident with diagnoses including unspecified mood affective disorder and anxiety disorder had an active care plan identifying problematic behaviors related to ineffective coping, such as verbal aggression, use of profanity, threats toward staff, and false accusations, with interventions that included avoiding arguments with the resident. On the date of the incident, two nursing assistants were conversing in the hallway about another staff member when the resident, from his bed, overheard the discussion, disagreed with what was being said, and yelled out his opinion, including profanity. One of the nursing assistants responded from the hallway, and a verbal exchange ensued between her and the resident, during which both parties used profanity. Interviews and record review confirmed that the nursing assistant engaged in an argument with the resident instead of avoiding confrontation, contrary to the resident’s care plan interventions. The resident reported that he became angry because the nursing assistants were talking about another employee whom he felt did a good job, and he described the nursing assistant as disrespectful and having no business arguing with him. Another nursing assistant who witnessed the event stated that the resident began yelling and cursing, telling them to stop talking about the employee, and that the involved nursing assistant argued back and used profanity. The DON and Administrator both acknowledged that the verbal exchange, including the use of profanity and arguing with the resident in the hallway, was unprofessional and should not have occurred.
Failure to Keep Quadriplegic Resident’s Mouth‑Blown Call Device Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure a quadriplegic resident’s specialized call light system was consistently placed within reach and accessible as care planned. The resident, who was cognitively intact but had impaired function in both upper and lower extremities and was dependent on staff for all ADLs, used a mouth‑blowing call device to summon assistance. The active care plan and Kardex documented the need for this device and noted the resident’s history of problematic manner behaviors, including calling 911 when not receiving timely attention, with an intervention to respond promptly to requests. During an observation, the resident was found lying in bed with the call device positioned too far from his mouth to activate it. He reported that while the device was usually placed correctly, there were times he had to yell out to staff in the hallway to have it repositioned because he could not move independently to reach it. On the same day, the NA assigned to the resident stated she was unaware the call device was out of reach, acknowledged it needed to be close enough to the resident’s mouth to function, and suggested it may have been moved during ADL care. She reported having been in the room within the last hour but could not recall checking the device’s placement, and stated the resident could yell out if he needed something. A subsequent observation on another day again found the resident in bed with the call device positioned above his head and out of reach; the resident confirmed he could not access it and stated he would yell out or use his voice‑activated phone to call the facility if he needed assistance, believing the device had been pushed away during morning care. The NA assigned that morning reported she had not seen the device out of reach and had not moved it, while a nurse reported the resident had asked her earlier to move the device closer and that she repositioned it. The DON stated she was unaware of issues with the device but confirmed the expectation that it should always be within the resident’s reach, while also noting the resident could make needs known by yelling or using his voice‑activated cell phone.
Failure to Deliver and Accurately Verify Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was delivered at the prescribed rate for a resident with chronic respiratory failure and COPD who was ordered continuous oxygen at 3 LPM via nasal cannula to maintain oxygen saturation above 90%. The resident’s care plan included oxygen therapy as ordered for COPD, and the admission MDS documented that the resident was cognitively intact and receiving oxygen therapy. On two separate observations, the surveyor noted the oxygen concentrator was set at 2.5 LPM when viewed at eye level, despite the physician’s order for 3 LPM. During these observations, the resident was resting in bed, denied shortness of breath, did not appear in respiratory distress, and stated she was supposed to receive 3 LPM of oxygen. A review of the MAR for the same period showed that a medication aide had documented the oxygen flow rate as 3 LPM on both days when the concentrator was actually set at 2.5 LPM. When observed and interviewed, the medication aide demonstrated that she adjusted and read the concentrator settings while standing over the machine rather than at eye level, initially asserting the setting was 3 LPM until asked to check at eye level, at which point she agreed it read 2.5 LPM and then adjusted it to 3 LPM. She stated she had assessed the concentrator on the prior days in the same manner and would notify the Unit Manager if there were problems. The Unit Manager reported she periodically checked oxygen settings but had not checked this resident’s concentrator on the days in question. The Medical Director and DON both stated the expectation that the resident receive oxygen at the ordered 3 LPM.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 27 opportunities, resulting in a 7.41% error rate. For one resident with atrial fibrillation and cardiomyopathy, the active physician order for March 2026 directed administration of metoprolol succinate 25 mg by mouth once daily, to be held only if systolic blood pressure was less than 110 or heart rate less than 60. On 4/1/26 at 9:00 AM, Nurse #3 obtained the resident’s blood pressure as 110/64 and heart rate as 79, which did not meet the ordered hold parameters. Despite this, Nurse #3 decided to hold the metoprolol succinate because the systolic blood pressure was close to the hold threshold, did not administer the ordered dose, and did not contact the physician at that time to obtain an order to hold the medication. For another resident with chronic obstructive pulmonary disease, the active physician order for March 2026 specified fluticasone propionate 0.05 mg/actuation nasal spray, 2 sprays in both nostrils once daily. On 4/1/26 at 9:12 AM, Nurse #3 handed the resident the nasal spray bottle without providing any instructions on its use. The resident then rapidly administered 3 sprays in the right nostril and 3 sprays in the left nostril, exceeding the ordered dose and using an incorrect technique, while Nurse #3 stood in front of the resident and did not intervene or correct the administration. After the resident returned the nasal spray, Nurse #3 left the room. In a subsequent interview, Nurse #3 stated that the resident preferred to administer her own nasal spray and liked to do it her own way, and acknowledged that she should have educated the resident when the medication was administered incorrectly.
Failure to Maintain Resident Privacy During Incontinence Care Due to Cellphone Use
Penalty
Summary
The deficiency involves a failure to maintain a resident’s personal privacy during incontinence care when a nurse aide used a personal cellphone in the resident’s room and a photo was captured showing the resident partially unclothed. The resident involved had diabetes type II, congestive heart failure, and peripheral vascular disease with a right below-the-knee amputation, was cognitively intact, frequently incontinent, and dependent on assistance for ADLs. During bowel incontinence care, the resident was lying on his right side facing the wall and window, with his entire buttocks uncovered and visible, feces present on the bed behind his buttocks, and only the back of his head and upper body partially clothed in a striped long-sleeved shirt visible. The DON and Administrator reported receiving an anonymous call stating that a nurse aide had taken a photo of a resident while providing incontinence care. The caller later sent the photo, which showed the resident’s backside, a leg amputation, part of a sweatshirt, and room surroundings including a window area, but not the resident’s face. Facility staff identified the resident by correlating the visible right BKA, clothing, and the window molding and room layout with the time period when the resident had been in a specific room. The DON and Administrator both described that the image depicted the resident partially clothed with his backside exposed while on the bed during care. NA #1 stated that she had been receiving repeated calls from her then-boyfriend on her personal cellphone while working and that she eventually answered via FaceTime with earbuds in while in the resident’s room. She reported that she told him she could not talk because she was at work and that she believed the phone must have captured an image of the resident’s backside as she was locking the phone and putting it away in her pocket. NA #1 acknowledged later learning that a picture of the resident’s backside, including his “booty,” had been captured, though she stated she was not sure exactly how it occurred. The resident later stated he did not remember the incident and, when asked, verbalized that if a picture had been taken of him during incontinence care with his buttocks showing, it would not bother him.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information as required, with discrepancies identified on 19 of 30 reviewed days. A comparison of the posted daily nurse staffing sheets to the internal nursing schedules for licensed and unlicensed staff showed multiple mismatches in the numbers and types of staff reported as working specific shifts. Examples included days when the posted sheets showed more nurse aides (NAs) or licensed practical nurses (LPNs) than were actually scheduled, fewer registered nurses (RNs) or medication aides (MAs) than scheduled, or shifts where an RN was listed as working on the posting despite none being scheduled. On several dates, the posted number of NAs on the 11:00 PM to 7:00 AM shift was higher or lower than the number on the schedule, and on other dates the number of LPNs or MAs on the 7:00 AM to 3:00 PM or 11:00 PM to 7:00 AM shifts did not match the schedule. During interviews, the Staffing Scheduler, who was responsible for managing the staffing schedule and daily postings, reviewed the records and confirmed that the posted daily staffing sheets did not match the actual staffing schedules for the reviewed period. She stated that she did not update the posted daily nurse staffing sheets when staff called out, were no-shows, or came in to cover staffing needs, resulting in inaccurate postings. The Administrator also stated that the daily staff schedule posting and the staffing schedule should match the number of staff who worked any given shift, confirming that the postings were expected to reflect actual staffing but did not do so on the identified dates.
Failure to Maintain Resident Rooms in Good Repair and Clean Condition
Penalty
Summary
Surveyors identified a deficiency in maintaining residents’ rights to a safe, clean, comfortable, and homelike environment when multiple resident rooms were found in disrepair and not properly maintained. Observations showed several rooms with scattered wall damage behind and beside beds, with exposed sheetrock and chalk-like wall material visible. In some rooms, scrape marks extended along the full length of the wall beside the bed, and one room had a large, scuffed area with a thick patch that had not been sanded or painted. Another room had multiple damaged wall areas behind the bed and a vinyl baseboard coming away from the wall under the sink, exposing the bare wall. These conditions were observed across several rooms on multiple hallways. In addition to wall and baseboard damage, one resident’s room contained a PTAC unit with a large amount of grey dust particles inside the top vents. The Maintenance Director acknowledged being aware that walls in resident rooms throughout the facility needed repair and reported being behind on room repairs and PTAC cleaning. He stated he was the only staff member in the maintenance department, had been in the role for one month, and had not completed his intended six‑month rounds for PTAC cleaning. He also indicated that recurring wall damage was likely caused by movement and adjustment of beds and wheelchairs, and that he had not finished repairs in at least one room. The Administrator acknowledged that resident rooms should be maintained in good repair and kept homelike.
Failure to Provide Routine Hair Trimming Services
Penalty
Summary
The facility failed to provide routine hair trimming services for residents who were unable to perform this activity of daily living themselves. This deficiency was identified for four residents who expressed dissatisfaction with the length of their hair and the lack of available services to address their needs. Each resident had been without a haircut for four months, and they were unable to recall which staff members they had spoken to about their requests. Observations confirmed that the residents' hair was longer than they preferred, indicating a lapse in the facility's provision of personal grooming services. Interviews with facility staff, including the Social Services Director, Activities Director, Director of Nursing (DON), and the Administrator, revealed a lack of awareness and responsibility regarding the provision of hair trimming services. The Social Services Director and Activities Director were unaware of the residents' requests and did not know whose role it was to provide haircuts. The DON, who had been in her position since October 2024, stated that she was not informed of her responsibility to find someone to cut residents' hair. The Administrator acknowledged the absence of a hairstylist and the lack of arrangements for residents to receive haircuts outside the facility. The facility's failure to provide hair trimming services was compounded by the lack of transportation arrangements for non-medical appointments, such as haircuts. While the facility had transportation available for medical appointments, it did not extend this service to personal grooming needs. The Administrator admitted to recruiting efforts for a hairstylist but was unaware of the residents' desire for haircuts, leading to a prolonged period without this essential service for the affected residents.
Medication Errors Due to Inadequate Training and Supervision
Penalty
Summary
The facility failed to prevent significant medication errors involving two residents. In the first incident, a nurse administered medications prescribed for another resident to a resident with severely impaired cognition. The medications included Eliquis, buspirone, gabapentin, isosorbide, metoprolol, spironolactone, and citalopram. The nurse, who was new and lacked sufficient training, realized the error after the resident reacted to the medication administration. The nurse notified the unit manager and the Director of Nursing but did not inform the resident's family member present at the time. In the second incident, another resident received medications intended for a different resident. The medications included Aricept, Lexapro, and Tramadol. The error was discovered when a precepting nurse questioned the new nurse about a scheduled injection that had not been administered. The precepting nurse then assessed the resident and notified the physician and responsible party. The new nurse was not adequately supervised during the medication preparation, leading to the error. Both incidents involved a new nurse who was not familiar with the residents and lacked adequate supervision and training. The errors were identified after the medications were administered, and the residents were monitored for adverse effects. The facility's administration acknowledged the errors and noted that the new nurse was no longer employed at the facility.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to prevent medication errors involving two residents. In the first incident, a nurse administered medications prescribed for another resident to a resident. The medications included fish oil and famotidine, which were intended for another resident. The error was identified when the resident questioned the medication, prompting the nurse to realize the mistake. The nurse immediately notified the unit manager, the Director of Nursing, and the Nurse Practitioner, who monitored the resident for any adverse effects. Fortunately, the resident did not experience any negative outcomes from the error. In the second incident, a resident with a diagnosis of anxiety was affected by two separate medication errors. The first error occurred when a nurse failed to administer the resident's morning dose of Ativan, as the medication remained stuck in the packaging and was not noticed until the shift change. The second error involved the same resident receiving a double dose of Ativan later that day. The nurse responsible for administering the medication did not verify the correct dosage, resulting in the resident receiving 1 mg instead of the prescribed 0.5 mg. Both errors were reported, and the resident was monitored for any adverse effects, with no harm reported. The facility's administrator acknowledged the medication errors and emphasized the expectation that nursing staff should administer the correct medications to the correct residents, in the correct dosage and route. The incidents highlight lapses in medication administration procedures, including verification and supervision during medication passes, which led to these errors.
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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 Albemarle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stanly Manor | 3.2 mi | ★★★★★ | 7 | 0 |
| Trinity Place | 3.6 mi | ★★★★★ | 2 | 0 |
| Forrest Oakes Healthcare | 4.3 mi | ★★★★★ | 5 | 0 |
| Mountain Vista Health Park | 16.9 mi | ★★★★★ | 1 | 0 |
| Cabarrus Health And Rehabilitation Center | 20.4 mi | ★★★★★ | 2 | 0 |
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