Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glendale Home-schdy Cnty Dept Social Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, MS, CHF, a history of falls, and anticoagulant use fell out of bed during care while a CNA was providing a one-person assist. After the first fall, the record did not show a nursing reassessment, therapy evaluation for safe bed mobility, or other new interventions beyond staff education. The resident later fell again during bed care, sustained abrasions, and was ultimately hospitalized with pelvic fractures, active hemorrhage, and pseudoaneurysms requiring embolization.
Pressure ulcer care was not consistently provided for multiple residents. One resident with MS, DM, and severe cognitive impairment had a left heel wound with inconsistent staging and also had a right heel wound and a lower left leg wound without weekly wound assessments. Another resident with a coccyx pressure injury had treatment documented but no weekly wound assessments, and an air mattress was noted in a provider note without a documented order. A third resident with osteomyelitis, MS, and DM missed wound treatment and weekly wound assessment when out for an appointment on the day wound rounds occurred.
Failure to Assess and Document Pain Before PRN Tramadol Administration: A resident with MS, DM, pressure ulcer history, and severe cognitive impairment had a care plan and facility protocol requiring pain assessment and documentation before and after pain meds. The resident received scheduled acetaminophen and later PRN tramadol for unspecified pain, but the record lacked a documented pain assessment, pain location/description, and evidence of provider notification before the tramadol order was obtained; nursing notes only documented that the medication was given, with limited follow-up documentation of effect.
Incomplete controlled substance count signatures were found on narcotic records for multiple units, with missing signatures from both oncoming and off-going nurses during shift counts. The facility policy required controlled meds to be counted at the end of each shift and signed by both nurses, and an LPN stated the narcotic book should be signed during the narcotic count and key hand-off at the beginning and end of every shift.
Improper Dating and Storage of Food Items: Surveyors found multiple open and ready-to-eat food items in the main kitchen and unit nourishment stations without required dates, along with food past its use-by date. Undated items included refrigerated and frozen foods, resident food brought from home, and opened bagels in a kitchenette refrigerator. The FSD stated staff were responsible for dating opened items and discarding items past their use-by date.
A CNA failed to use EBP during toileting care for a resident with ESBL history and severe cognitive impairment, despite a sign outside the room indicating precautions. In a separate event, an LPN placed g-tube medication supplies directly on a bedside table, dropped a cup of crushed medication on the floor, and then administered the same dose without discarding and repreparing it.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Two residents who were cognitively intact but dependent for ADLs did not receive care as planned. One resident with post-stroke hemiplegia and other medical conditions had no documented baths or showers on two scheduled evening shifts within the initial admission period, despite being care planned for substantial/maximal assist with bathing. Another resident with a hip fracture, heart failure, and paroxysmal atrial fibrillation, care planned for extensive one-person assist with transfers and toileting and bowel documentation every shift, had multiple shifts in which toileting assistance was not documented. Staff reported that showers and care should occur as scheduled and be rescheduled and communicated if missed, but the records did not reflect that this occurred for these residents.
A resident with CAD, PVD, and COPD, who was cognitively intact, reported severe (10/10) pain and trouble breathing after family alerted staff that the resident felt very sick. An RN documented stable VS and no acute distress, and later an NP was contacted and adjusted pain medications. That evening, nursing notes described a significant two-day decline with minimal intake, continuous sleeping, and persistent 10/10 foot pain despite the new regimen, but there was no documented provider notification of this ongoing uncontrolled pain and change in condition. By early the next morning, the resident was very lethargic, non-responsive, hypotensive, and was then sent to the ER, where they were diagnosed with toxic metabolic encephalopathy likely due to severe sepsis from gram-negative pneumonia. The NP stated nurses were expected to call back with reassessment if pain remained uncontrolled, the DON was unaware of the change in condition, and an RN acknowledged documentation should have been better, demonstrating a failure to follow change-of-condition and quality-of-care policies.
A resident with Cerebral Ischemia, anxiety, and depression reported that the facility’s laundry service did not return several nightgowns, with the missing items increasing from three to five and leaving the resident without nightgowns. An RN said two new nightgowns were being labeled but could not account for the other three, while the resident’s representative said replacement nightgowns had been sent because laundry items were often missing.
Unnecessary psychotropic medication use was identified for multiple residents. Two residents had PRN lorazepam orders that exceeded the 14-day limit, one resident on aripiprazole had no documented GDR attempt or clinical contraindication, and another resident had an antipsychotic without an appropriate dx. The facility policy required PRN psychotropics to be limited to 14 days and annual GDR attempts unless clinically contraindicated.
Failure to Timely Report Injury of Unknown Origin: A resident with quadriplegia and intact cognition was found to have acute tibia/fibula fractures on x-ray after right leg redness and warmth were evaluated for cellulitis. The DON and IDT concluded the injury was self-inflicted and did not report it as an injury of unknown origin within the required 2-hour window, despite the resident being unable to identify how the fracture occurred.
Failure to obtain psychiatric follow-up for a resident with hemiplegia, anxiety disorder, and bipolar disorder. The resident was cognitively intact and receiving psychotropic medication, with management deferred to psych services, but a psychiatric consult called for follow-up in 2 to 3 weeks and no follow-up was scheduled or completed. The MD stated psych services should have been involved, while the NP assumed the resident was being seen and the RN said staff had not arranged the appointment.
Medication Pass Failed to Include Expiration Date Checks: During a medication pass, an LPN administered medications to two cognitively intact residents without checking expiration/beyond use dates, despite facility policy requiring the dates be checked before administration. One resident received five medications and another received five medications, and the LPN stated they did not routinely check expiration dates prior to giving meds.
Failure to Reassess and Supervise Bed Mobility After Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who was at high risk for falls and bleeding. The resident had diagnoses including congestive heart failure, multiple sclerosis, and a history of falling, and the Minimum Data Set documented severe cognitive impairment and total dependence on staff for bed mobility. The resident’s care plan identified fall risk, anticoagulation therapy with Eliquis, and the need for staff to avoid bumping and to handle the resident gently during hands-on care. Nursing instructions also directed one-person physical assist for bed mobility. After an observed fall out of bed during care, the resident was found on the floor with no injury. The incident documentation stated the resident rolled out of bed while a CNA turned around to get more linen, but there was no documented evidence that nursing reassessed fall risk, assessed whether the resident could safely receive bed mobility care with one staff member, or implemented new interventions to reduce the risk of another accident. The fall risk assessment completed later showed a higher fall risk score than before, but the record did not show a therapy evaluation for safe bed mobility or other new interventions after the fall. The resident later fell out of bed again while care was being provided by one CNA and sustained abrasions. The care plan was updated to add two-person assist for bed mobility and hygiene, but the resident subsequently had a change in condition and was sent to the hospital, where imaging showed pelvic fractures, active hemorrhage, and multiple pseudoaneurysms requiring embolization of the right internal pudendal artery. Survey interviews with nursing leadership confirmed they could not explain why no additional interventions were implemented after the first fall and acknowledged that therapy evaluation or a two-person assist could have been considered, while the medical director stated it was the responsibility of nursing staff to implement interventions to prevent accidents.
Pressure ulcer care and wound assessment failures
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The deficiency involved three residents and included inconsistent wound staging, missing weekly wound assessments, and incomplete wound treatment oversight. The report states that the facility did not ensure proper documentation and follow-through for pressure injuries affecting the heel, coccyx, and lower leg, despite physician orders and care plan interventions calling for daily treatment and weekly assessment. For one resident with multiple sclerosis, diabetes, and severe cognitive impairment, the left heel wound was documented inconsistently over time. The wound was first identified as a deep tissue injury, later described as having opened and as having two blisters, then later documented again as a deep tissue injury or unable to determine. The record also showed that the anatomical drawing initially conflicted with the assessment data. In addition, the resident had a right heel pressure injury and a pressure ulcer on the back of the lower left leg, but the record did not contain weekly wound assessments for either wound while treatment orders were in place. For another resident with fractures, diabetes, and a coccyx pressure ulcer, the wound was identified as stage 2 and treated from the time it was first documented through the end of the review period, but the record did not show weekly wound assessments while the wound was being treated. The medical note also documented an air mattress for the coccyx wound, but there was no documented order for the air mattress in the record. For a third resident with osteomyelitis of the spine, multiple sclerosis, and diabetes, wound care orders were in place for a stage 4 coccyx wound and an unstageable left heel wound, but when the resident was out of the facility for an appointment on the day the in-house wound care provider completed rounds, the treatment record did not show wound treatment that day and there was no documented weekly wound assessment for that week.
Failure to Assess and Document Pain Before PRN Tramadol Administration
Penalty
Summary
Pain management was not provided in accordance with professional standards of practice and the resident’s comprehensive care plan for one resident with multiple sclerosis, diabetes, pressure ulcer history, and severe cognitive impairment. The resident’s care plan called for ongoing assessment of pain, including onset, location, description, intensity, and aggravating or alleviating factors, and for medications to be administered as ordered. The facility also had a pain management protocol requiring pain to be monitored and documented before and after pain medication, with follow-up documentation within one hour of administration and a progress note reflecting the medication and effect for each dose. The resident had standing acetaminophen ordered every eight hours and later received a new PRN tramadol order for unspecified pain. Survey review found no documented evidence of a pain assessment or physician notification before the tramadol order was obtained, and the medication record and nursing notes did not document the description or location of the pain. Tramadol was administered multiple times, but the notes only stated that it was given, and in two instances that it had a positive effect, without documenting the pain details required by the care plan and facility protocol. The DON stated the resident should have had a pain assessment before the on-call provider was contacted, and the RN involved stated she did not recall the order and believed the supervisor would have handled the provider call and documentation.
Incomplete Controlled Substance Count Signatures
Penalty
Summary
The facility failed to maintain and account for controlled substances in accordance with professional standards of practice. A review of the narcotic count record book showed incomplete signature documentation on the controlled substance count sheets for three of five units, including Mohawk Trail side A, Mohawk Trail side B, Union Station side B, Union Station side A, and Dutch Hollow side B. The missing entries included blank spaces where the off-going nurse or oncoming nurse did not sign for multiple shift counts, such as at 03:00 PM, 11:00 PM, and 07:00 AM on various dates. The facility policy titled Controlled Substances, dated 04/2025, stated that controlled medications are counted at the end of each shift and that the nurse coming on duty and the nurse going off duty determine the count together and both sign the designated controlled substance record. During an interview on 4/24/2026 at 9:47 AM, an LPN stated the narcotic book should be signed when nurses complete the narcotic count and hand-off of keys at the beginning and end of every shift.
Improper Dating and Storage of Food Items
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional food service standards in the main kitchen and in 2 of 5 kitchenettes/nourishment stations. During the survey, open food items were found without dates showing when they were opened, including chocolate syrup, a bag of donuts, several frozen breakfast and chicken items, and an open bag of gluten free chicken nuggets. A bag of cut-up potatoes in Refrigerator 2 was also found past its use-by date, marked 4/07/2026. In the Dutch Hollow nourishment station, food brought from home for a resident was found with multiple dates, including soup dated 4/13/2026, 4/14/2026, and 4/15/2026, along with food in an undated paper bag, hot dogs with a sell-by date of 2/25/2026, a slice of cheese dated 3/30/2026, and a plate of tortilla chips that was not dated or labeled. At [NAME] Crossing, the kitchenette refrigerator contained bagels in an opened plastic bag that was undated. The Food Service Director stated that staff were responsible for dating opened items and that items past their use-by date should be discarded.
Infection Control Lapses During Toileting and G-Tube Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two residents reviewed for infection control practices. One resident had Alzheimer’s disease, angina, and nonthrombocytopenic purpura, with severe cognitive impairment, frequent urinary incontinence, and substantial assistance needs for toileting hygiene. The resident also had a history of ESBL and was on Enhanced Barrier Precautions for colonized ESBL, but during an observation a CNA assisted the resident with toileting without wearing a gown and gloves. The CNA stated they did not know the resident was on Enhanced Barrier Precautions or why, despite a precaution sign being present outside the room. A second resident had congestive heart failure, hypertension, and gastrostomy status, and was understood and able to understand others with intact cognitive function. During an observation, an LPN placed the resident’s medication cup and gastrostomy tube flushing supplies directly on the bedside table without a barrier. The LPN then dropped the cup containing crushed medication on the floor, picked it up, and administered the medication to the resident without discarding and repreparing the dose. The facility policy stated staff should follow established infection control procedures, including antiseptic technique, during medication administration.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
Failure to Provide and Document Scheduled Bathing and Toileting Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living in accordance with professional standards for two cognitively intact, dependent residents. One resident with hemiplegia following a prior stroke, essential hypertension, and hypo-osmolality/hyponatremia was care planned as requiring substantial/maximal assistance for bathing and extensive assist of two for bed mobility and transfers. The CNA accountability record for bathing showed no documented evidence that this resident received a bath or shower on two scheduled evening shifts in late December, including within the first two weeks after admission. This lack of documented bathing occurred despite the resident’s identified need for extensive assistance with all ADLs. Another resident with a displaced intertrochanteric fracture of the right femur, heart failure, and paroxysmal atrial fibrillation was care planned as requiring extensive one-person assistance for transfers, ambulation, and toileting, with CNAs directed to document bowel elimination every shift. Review of CNA toileting documentation for July showed multiple shifts with no recorded toileting assistance, including several day, evening, and night shifts across the month. During interviews, a CNA and an LPN stated that residents should receive showers on their scheduled days and that any missed showers or care would be reported to nursing and rescheduled, but the records for these two residents did not show that the planned toileting and bathing care was provided or documented as required.
Failure to Notify Provider and Respond to Resident’s Significant Decline and Uncontrolled Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding change in condition. The resident had diagnoses including CAD, PVD, and COPD and was documented as cognitively intact. On one day, the resident’s daughter called reporting that the resident said they were "very, very sick." An RN assessed the resident, noting stable vital signs, clear upper lung sounds, refusal of lower lobe assessment, complaint of trouble breathing, oxygen saturation of 90%, and refusal of oxygen and dressing change. The RN informed the daughter that the resident was not in acute distress and not dying. Later that day, the NP on call was notified of the resident’s uncontrolled pain rated 10/10, and new orders were obtained for scheduled and PRN pain medications. That evening, nursing documentation described a significant decline over the prior two days, including minimal intake, no eating, sleeping throughout the 15:00–23:00 shift, and continued 10/10 left foot pain despite the earlier medication adjustment. The resident was lethargic but could be roused to take medications before returning to sleep. Despite this documented significant decline and persistent severe pain, there is no documentation that the provider was notified at that time of the change in condition or ongoing uncontrolled pain, contrary to the facility’s change of condition and quality of care policies that require timely evaluation and provider notification when changes occur. In the early morning hours of the following day, the resident was documented as very lethargic and non-responsive, with hypotension, bradycardia, low temperature, and an inability to obtain an oxygen saturation reading. At that point, the NP ordered transfer to the ER, where the resident was diagnosed with toxic metabolic encephalopathy likely in the setting of severe sepsis due to gram-negative pneumonia. The NP later stated that if pain was not controlled, nursing staff were expected to call back with reassessment findings, including vital signs, mental status, and history, for further direction. The DON reported not being aware of the resident’s change in condition during this period, and an RN interviewed acknowledged that documentation for this resident should have been better. These actions and omissions demonstrate that the facility did not promptly identify, evaluate, and communicate the resident’s change in condition and persistent severe pain in accordance with its policies and professional standards.
Missing Resident Nightgowns
Penalty
Summary
The facility did not ensure that a resident’s personal property was free from loss or theft, as Resident #43 reported missing laundry items and said five nightgowns were not returned. The resident stated the facility did their laundry and that blue and pink nightgowns had not been returned in a timely manner; what began as three missing nightgowns had increased to five, leaving the resident with no nightgowns. The resident also stated they had told several staff members about the missing items. Resident #43 was admitted with diagnoses of Cerebral Ischemia, Anxiety, and Depression, and the MDS dated 09/11/2024 documented that the resident could be understood, understood others, and was cognitively intact. During interviews, an RN stated the resident had not reported missing laundry to them and acknowledged that two new nightgowns had been delivered and were being labeled, while the whereabouts of the other three were unknown. The resident representative stated they had sent three replacement nightgowns to the facility because the resident had no nightgowns and reported that laundry items were often missing. The Social Work Director and Administrator stated missing items were tracked, searched for, and replaced if not found.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications for 4 of 6 residents reviewed. The report states that the facility’s policy required as-needed psychotropic drugs to be limited to 14 days and that a gradual dose reduction must be attempted annually unless clinically contraindicated. During the survey, Residents #55 and #97 were both found to have lorazepam as-needed orders with end dates outside the regulatory 14-day limit. Resident #55 had diagnoses including vascular dementia, atrial fibrillation, and major depressive disorder, and was severely cognitively impaired. Resident #97 had diagnoses including Alzheimer’s disease, anemia, and depression, and was also severely cognitively impaired. Resident #13 was admitted with hemiplegia following cerebral infarction, generalized anxiety disorder, and bipolar disorder, and was cognitively intact. The resident had an order for aripiprazole 10 mg daily for bipolar disorder, but the record did not show documented attempts at gradual dose reduction or documentation that gradual dose reduction was clinically contraindicated. Resident #155 was also identified as having an antipsychotic medication without an appropriate diagnosis. The report further notes that the Medical Director stated as-needed psychotropic medications should have a 14-day end date, with longer duration only when the reason is documented, and the Physician’s Assistant stated the duration for as-needed psychotropics should be 14 days.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Survey Agency within the required two-hour window after identifying serious bodily injury for one resident. The resident was admitted with quadriplegia, paroxysmal atrial fibrillation, and GERD, and was documented as cognitively intact and able to understand and be understood. Portable imaging of the right lower extremity showed acute oblique/spiral fractures of the distal tibial and fibular diaphysis, and the resident was sent for hospital treatment after the results were reviewed and communicated to the nurse practitioner, medical director, administrator, DON, social work, and the resident. The facility’s incident investigation documented that the resident had been treated for cellulitis of the right leg, but redness did not resolve, prompting an x-ray that revealed the tibia/fibula fracture. The resident stated they were not sure how the injury occurred and later said they thought they may have caught the edge of their shoe on the side of the elevator and twisted it, while also denying abuse and fear of staff. The DON stated the injury was not considered reportable because the interdisciplinary team and resident felt it was self-inflicted, despite acknowledging awareness of the two-hour reporting window for injuries of unknown origin.
Failure to Obtain Psychiatric Follow-Up
Penalty
Summary
The facility failed to obtain necessary psychiatric treatment and services for a resident with hemiplegia following cerebral infarction, generalized anxiety disorder, and bipolar disorder. The resident’s MDS documented that the resident was cognitively intact, able to be understood, and able to understand others. A psychiatric consultation dated 8/13/2025 documented follow-up in two to three weeks, but there was no follow-up scheduled or completed. Medical notes dated 09/01/2025, 12/04/2025, 01/12/2026, 02/08/2026, 03/09/2026, and 04/05/2026 documented that the resident was receiving psychotropic medication and that management was to be deferred to psychiatric services. During interviews, the Medical Director stated the resident should have had psychiatric services involved. The NP stated they assumed the resident was being seen by psychiatric services but had not read any consultations, and the RN stated nurses were supposed to arrange follow-up appointments but had not made the follow-up appointment and did not know why the lapse occurred.
Medication Pass Failed to Include Expiration Date Checks
Penalty
Summary
The facility failed to ensure that its medication error rate did not exceed 5 percent during a medication pass observation involving eight residents and 35 medication observations, resulting in a 31.43 percent error rate. The facility policy titled "Administering Medications" required that the expiration/beyond use date be checked before administering a medication, but this was not done during the observed pass. Resident #32, who had diagnoses including essential primary hypertension, herpes viral ocular disease, and hyperlipidemia and was cognitively intact, was observed receiving propranolol, aspirin, losartan, valacyclovir, and Myrbetriq. The LPN reviewed the MAR and prepared the medications, but had difficulty locating the expiration date on the propranolol blister card and then administered the remaining medications without checking their expiration dates. Resident #57, who had diagnoses including multiple sclerosis, an esophageal ulcer with bleeding, and essential primary hypertension and was also cognitively intact, was observed receiving tamsulosin, pantoprazole, baclofen, gabapentin, and metoprolol succinate ER. The LPN prepared all five medications for administration without checking expiration dates for any of them. During interview, the LPN stated they did not routinely check expiration dates prior to administering medication.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Scotia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pathways Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Baptist Health Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 17 | 0 |
| Ellis Residential & Rehabilitation Center | 4.9 mi | — | 0 | 0 |
| Schenectady Center For Rehabilitation And Nursing | 5.8 mi | ★★★★★ | 0 | 0 |
| Seton Health At Schuyler Ridge Residential H C | 6.4 mi | ★★★★★ | 0 | 0 |
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