Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Town East Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, multiple chronic conditions, severe cognitive impairment, incontinence, wheelchair use, and complete dependence for ADLs had a documented history of a recent fall and a comprehensive care plan that included a bedside floor mat as a fall-prevention intervention. During two observations, the resident was found in bed with the call light in reach but without the care-planned floor mat at the bedside. An LVN, the DON, and the Administrator each confirmed that a floor mat was an established intervention following the resident’s fall and that bedside nursing staff were responsible for ensuring its presence, while the facility’s policy required implementation of all comprehensive person-centered care plan interventions.
A CNA provided in-bed care alone to a dependent male resident with multiple neurological and physical impairments, despite the care plan and Kardex requiring two-person assistance. The resident fell from the bed and sustained a head laceration requiring sutures. The CNA admitted to not checking the Kardex, and facility leadership showed inconsistent understanding of the resident's assistance needs, leading to neglect and resident injury.
A resident with significant cognitive and physical impairments, requiring two-person assistance for bed mobility and care, was injured when a CNA provided care alone and the resident rolled off the bed, sustaining a head laceration. The CNA did not check the care plan or Kardex for required assistance level, and other staff confirmed the need for two-person assist was documented. The incident resulted in the resident being sent to the hospital for treatment.
Six medication carts were found unlocked and unattended at the nurses' station, with drawers facing outward toward the hallways. Multiple staff, including LVNs and a CMA, confirmed that medication carts should be locked when not in use, but could not explain why the carts were left unsecured. The facility's policy requires all drugs and biologicals to be stored in locked compartments, and staff interviews confirmed this expectation.
A resident with significant medical needs, including G-tube feeding, had their feeding pump paused by CNAs who were not licensed or formally trained to operate the equipment. Multiple staff interviews confirmed that only licensed nurses should handle G-tube pumps, but CNAs routinely paused them during care, and there was no clear facility policy specifying authorized personnel for this task.
A resident with hemiplegia and hemiparesis was found to have their call light out of reach, despite being bed-bound and dependent on assistance. Staff interviews revealed awareness of the importance of call light accessibility, but inconsistent adherence to the policy. The facility's policy requires call lights to be accessible, but this was not effectively implemented, leading to a deficiency in accommodating the resident's needs.
A resident with dementia and hemiplegia did not have a comprehensive care plan addressing her ADLs and left-hand contraction. Despite being dependent on staff for personal hygiene, her care plan lacked necessary interventions. Facility staff, including the DON and MDS Coordinators, acknowledged the oversight, which could impact resident care.
The facility failed to maintain proper hygiene and nail care for two residents, one with severe cognitive impairment and total dependence, and another with dementia requiring moderate assistance. Both residents were found with long, dirty, or chipped fingernails, posing risks of infection and self-injury. Staff acknowledged the need for regular nail care, especially for diabetic residents, as per facility policy.
A resident with a history of stroke and a contracted left hand was using a soft hand roll without a physician's order. Despite the resident's cognitive intactness and the use of the hand roll since admission, staff interviews revealed a lack of awareness about the need for an order. The absence of a documented order could lead to improper application and potential risk, although no immediate skin issues were noted.
The facility failed to deliver mail to residents on Saturdays, as reported by five residents during an interview. The Director confirmed mail distribution occurred only Monday through Friday, and the weekend receptionist lacked a key to access the mail lockbox. The Administrator was unaware of this issue, which contradicted the facility's policy requiring mail delivery within 24 hours, including Saturdays.
A facility failed to administer a COVID-19 test and nasal spray to a resident as ordered by a nurse practitioner. The test order was miscategorized, delaying its execution, and the nasal spray order was placed in the MAR instead of the TAR, leading to missed doses. Staff interviews revealed a lack of awareness and understanding of the orders, with the DON acknowledging errors in order categorization.
The facility's kitchen failed to meet food safety standards by not labeling potato rolls with expiration dates and not ensuring staff used proper hair restraints. Observations revealed that staff members had unsecured hair while preparing and serving food, risking contamination. Interviews confirmed awareness of these requirements, but lapses occurred, potentially endangering residents' health.
The facility failed to implement its Water Management Program to prevent Legionella bacteria growth, as no testing was conducted in June and July 2024. Additionally, a CNA did not follow proper PPE protocols when entering a resident's room on COVID-19 isolation precautions, wearing only a mask and gloves instead of full PPE. The CNA was unclear about PPE expectations for non-direct care tasks, despite signage and verbal reminders from the DON.
The facility failed to maintain proper hygiene for two residents, resulting in unclean and untrimmed fingernails. Both residents required assistance with personal hygiene due to cognitive and physical impairments. Despite care plans specifying regular nail maintenance, observations showed neglect in this area. Interviews with staff confirmed the responsibility for nail care was shared between CNAs and nurses, with specific protocols for diabetic residents. The facility's policy on nail care was not adhered to, leading to the deficiency.
The facility failed to ensure proper pharmaceutical services, as observed with a medication cart managed by an LVN. Blister packs for a resident's lorazepam and another's tramadol had broken seals with pills still inside, indicating a lapse in procedures for drug management. Interviews revealed that the LVN did not check blister packs during shift changes, contrary to facility protocol, which contributed to the deficiency.
A facility failed to secure medications as required, leaving a resident's nasal spray and inhaler on the bedside table instead of in a locked compartment. The resident, with moderate cognitive impairment and chronic respiratory issues, had not used the medications since they were left there by a nurse. Interviews with staff confirmed that medications should not be left unsecured.
Failure to Implement Care-Planned Bedside Fall Mat for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan for one resident with a history of falls. The resident was an elderly male with dementia, respiratory failure, spinal stenosis, heart disease, and diabetes, who was severely cognitively impaired with a BIMS score of 01, always incontinent of bowel and bladder, had a recent fall, used a wheelchair for mobility, and was completely dependent on staff for transfers, toileting, showers, and dressing. His comprehensive care plan, dated 12/26/2025, documented an actual fall with no injury and included specific fall-prevention interventions such as a floor mat, anticipating needs, and ensuring the call light was within reach. On two separate observations on the same day, the resident was seen resting comfortably in bed with his call light within reach, but no floor mat was present at the bedside despite it being a listed care plan intervention. An interview with the LVN assigned to the resident confirmed that he had fallen about a month prior and that his fall precautions included a fall mat, which she stated should have been at the bedside; she was unsure why it was not in place and acknowledged it was her responsibility to ensure its presence. The DON and the Administrator both stated that the resident had a fall and that a bedside floor mat while resting in bed was one of the interventions, and each affirmed that it was the bedside nurse’s responsibility to ensure the mat was present. The Administrator also stated there was no specific fall mat policy but that she expected all interventions listed on the comprehensive care plan to be implemented, consistent with the facility’s written policy requiring development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables.
Failure to Follow Care Plan Results in Resident Injury Due to Inadequate Assistance
Penalty
Summary
A certified nursing assistant (CNA) failed to follow the care plan for a male resident with multiple diagnoses, including cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff, requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this, the CNA attempted to provide in-bed care alone, turned the resident onto his side, and the resident subsequently rolled off the bed, sustaining a laceration to the left forehead that required sutures and hospital evaluation. The CNA admitted to not checking the Kardex to confirm the required level of assistance and stated she had always provided care to this resident alone, unaware of the two-person assist requirement. The care plan and Kardex both indicated the need for two-person assistance, but this was overlooked. The incident was witnessed by another staff member, and the resident was found on the floor with active bleeding. The nurse on duty confirmed that the CNA did not request help and that the care plan clearly required two-person assistance for bed mobility and transfers. Interviews with facility leadership revealed inconsistent understanding of the resident's care requirements, with the DON initially believing the resident was a one-person assist and only learning of the two-person requirement after the incident. The administrator did not conduct an independent investigation and relied on the DON's report, attributing the incident to a possible typo in the care plan and oversight by the CNA. The failure to follow the care plan and ensure staff were aware of and adhered to residents' assistance needs resulted in the resident's injury and constituted neglect as defined by facility policy.
Removal Plan
- CNA A in-serviced one-on-one by DON on resident positioning, bed mobility, using draw sheet, and getting assistance when needed.
- CNA A terminated and has not worked since.
- All staff in-serviced on Abuse/Neglect/Exploitation, Incidents/Accidents, and how to safely care for dependent residents, completed by ADON with Compliance Nurse oversight.
- DON/Administrator in-serviced on Abuse, Neglect, Incidents, and Investigating, including immediate suspension of employee accused of abuse/neglect, completed by Compliance Nurse.
- 100% audit completed to review plan of care, Kardex, and care profile on residents who are dependent assistance, completed by DON/ADON or designee with Compliance Nurse oversight.
- Care guides reviewed for compliance and accuracy, completed by DON/ADON or designee with Compliance Nurse oversight.
- Nursing staff in-serviced on guidance for accessing Kardex, care plans, and how to safely care for residents with positioning and incontinent care, completed by DON/ADON/designee.
- Weekend supervisor trained to monitor incidents/accidents on weekends and immediately report any issues identified to Administrator/DON by DON.
- All incidents reviewed and no other instances of abuse or neglect noted from the audit, completed by DON/Admin.
- Incident with Resident #1 self-reported via email by DON.
- Investigation initiated; facility self-reported the incident.
- All Abuse/Neglect allegations will be reported and investigated per policy; DON and Administrator will ensure investigations are completed timely.
- Administrator oversight provided by Regional President of Operations.
- No employees will be allowed to return to work until they have been in-serviced on the Abuse/Neglect policy and how to safely care for residents.
- Nurses will be responsible for ensuring compliance; DON/ADON/Admin will monitor.
- Incidents/Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor, and reported to Administrator immediately for investigation.
- Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents.
- Admin/DON will monitor to ensure compliance.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during care for a resident with significant physical and cognitive impairments. The resident, who had a history of cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness, was assessed as requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this documented need, the CNA provided care alone, turned the resident on his side, and the resident subsequently rolled off the bed, sustaining a laceration to the forehead that required hospital treatment. The incident was witnessed and documented by nursing staff, who responded to the scene and provided immediate care, including applying pressure to the wound and arranging for hospital transfer. Interviews with staff revealed that the CNA was unaware of the resident's two-person assist requirement and had not checked the Kardex or care plan prior to providing care. Other staff members, including nurses and administrative personnel, confirmed that the resident's care plan and Kardex indicated a two-person assist was necessary, and that the CNA did not request help as required by facility policy. Further investigation showed that the CNA had a history of working with the resident and had previously provided care alone, indicating a lack of adherence to established protocols. The Director of Nursing (DON) and Administrator acknowledged that the CNA did not follow the care plan and facility policy, and that there was a failure to ensure staff were consistently aware of and following residents' required levels of assistance. The incident resulted in the resident sustaining an injury due to inadequate supervision and assistance during care.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by policy and professional standards. During an observation, six medication carts located at the nurses' station were found unlocked with drawers facing outward toward the hallways, and no staff was present at the station. Multiple staff interviews confirmed that medication carts should be locked when not in use, regardless of their location, and staff were unable to explain why the carts were left unlocked. The facility's policy, revised in April 2019, specifies that all drugs and biologicals must be stored in locked compartments, and nursing staff are responsible for maintaining secure medication storage areas. The surveyor's findings were based on direct observation, staff interviews, and a review of facility policy. Staff members, including LVNs and a CMA, acknowledged the expectation that medication carts remain locked when not in use, but could not provide a reason for the lapse. The Regional Nurse also confirmed that leaving medication carts unlocked, even at the nurses' station, was not acceptable and posed a risk. The surveyor did not determine which staff members were responsible for leaving the carts unsecured.
Unlicensed Staff Adjusted G-Tube Pumps Without Proper Training or Authorization
Penalty
Summary
The facility failed to ensure that only licensed and trained nursing staff adjusted gastrostomy tube (G-tube) pumps for a resident who was dependent on enteral feeding due to multiple medical conditions, including hemiplegia, aphasia, bed confinement, moderate protein-calorie malnutrition, and a history of intracerebral hemorrhage. Record reviews and staff interviews revealed that unlicensed staff, specifically CNAs, were placing G-tube pumps on hold during routine care such as changing and repositioning the resident. These CNAs reported that they had learned how to pause the pumps by observing nurses, but did not have formal training or knowledge of the risks involved. Multiple licensed nurses confirmed that only licensed staff should handle G-tube pumps, but acknowledged that CNAs commonly paused the pumps and that there was no clear policy specifying who was responsible for this task. The deficiency was further evidenced by the lack of a specific facility policy outlining which staff members were authorized to operate G-tube pumps. The Regional Nurse confirmed that only licensed staff were expected to handle the pumps, but also acknowledged the absence of a written policy. Documentation showed that the issue came to light after a CNA reported a resident vomiting, and it was discovered that CNAs had been pausing the G-tube pump without proper authorization or training. The resident involved was unable to communicate due to cognitive and physical impairments.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident in question, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed to be bed-bound and dependent on assistance for personal care. During an observation, the resident's call light was found hanging towards the floor and not within reach, which the resident confirmed was a recurring issue. Interviews with facility staff, including CNAs and an LVN, revealed that while they were aware of the importance of keeping the call light within reach, there was a lapse in ensuring this was consistently done. Staff members acknowledged the potential risks associated with not having the call light accessible, such as falls, injuries, and delays in care. Despite receiving in-service training on the importance of call lights, the staff did not consistently adhere to the policy of ensuring the call light was accessible to the resident. The facility's Director of Nursing and Administrator both emphasized the responsibility of all staff to ensure call lights are within reach to prevent risks such as falls, injuries, and other adverse outcomes. The facility's policy on answering call lights, revised in September 2022, clearly states the need for call lights to be accessible from various locations, including the bed. However, the deficiency indicates a failure in implementing this policy effectively, leading to the resident's inability to call for assistance when needed.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident, specifically addressing her Activities of Daily Living (ADLs) needs. The resident, a cognitively intact female with a history of dementia and cerebrovascular accident resulting in hemiplegia, was dependent on staff for personal hygiene and showering. Despite these needs, her care plan did not include interventions for her ADLs or her left-hand contraction, which was managed with a soft hand roll to prevent discomfort. Interviews with facility staff, including the Director of Nursing (DON) and MDS Coordinators, revealed that the care plans were not updated to reflect the resident's current needs. The MDS Coordinator responsible for the care plans acknowledged the oversight and the potential impact on resident care, as staff would be unaware of necessary interventions. The facility's policy requires comprehensive, person-centered care plans to meet residents' needs, but this was not adhered to in this case.
Failure to Maintain Resident Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #1, a male with severe cognitive impairment and total dependence for all ADLs, was observed with long and dirty fingernails. Despite his inability to communicate verbally due to aphasia, he indicated through nodding that he wanted his fingernails trimmed and cleaned. A CNA confirmed the condition of his nails and acknowledged the potential health risks, including infection and self-injury. Resident #2, a female with dementia and moderate assistance needs for personal hygiene, was also found with long and chipped fingernails. She expressed a desire to have her nails trimmed. A CNA and an LVN both recognized the need for nail care and the associated risks of infection and skin breakdown. The facility's policy required nail care to be performed regularly, especially for residents with diabetes, where only nurses were permitted to trim nails. The DON stated that nail care should be provided every shower day and as needed, and acknowledged that dirty fingernails could pose an infection control issue.
Lack of Physician's Order for Soft Hand Roll
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for the use of a soft hand roll for her contracted left hand. This deficiency was identified during an observation, interview, and record review process. The resident, who is cognitively intact with a BIMS score of 15/15, has a history of stroke resulting in hemiplegia and a contracted left hand. Despite the resident's use of a soft hand roll since her admission, there was no documented physician's order for this device in her care plan or physician's orders. Interviews with staff, including a CNA, RN, DON, PT Director, and the Administrator, revealed a lack of awareness regarding the necessity of a physician's order for the soft hand roll. The CNA and RN were unaware of the requirement, and the DON and PT Director admitted to not knowing that an order was needed. The Administrator acknowledged that it was the nurse's responsibility to ensure an order was in place. The absence of a physician's order for the soft hand roll could lead to improper application and potential risk to the resident, although no immediate skin issues were observed.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive mail on Saturdays, which is a deficiency in promoting residents' access to communication methods. During a confidential group interview, five residents reported that mail was only delivered from Monday to Friday, coinciding with the business office's operational days, and not on weekends. The Director confirmed that mail was distributed Monday through Friday and mentioned that the weekend receptionist was supposed to distribute mail on weekends. However, the Director was unsure if the receptionist had a key to the lockbox where mail was left by the carrier. The Administrator was unaware of the issue and confirmed that the weekend receptionist did not have a key to access the mail on Saturdays. The facility's policy stated that mail should be delivered to residents within 24 hours of delivery, including Saturdays, which was not being adhered to.
Failure to Administer COVID-19 Test and Nasal Spray
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care according to professional standards of practice. Specifically, the facility did not promptly administer a COVID-19 test for a resident when it was ordered by a nurse practitioner. The order for the test was placed under the wrong category, which resulted in it not being added to the Treatment Administration Record (TAR) and subsequently not being carried out in a timely manner. The resident, who was cognitively intact and had a history of cerebrovascular disease, hypertension, and hyperlipidemia, was experiencing nasal congestion and a slight cough at the time. Additionally, the facility did not follow the nurse practitioner's order for a nasal spray for the same resident. The order for the nasal spray was incorrectly categorized, leading to it being recorded in the Medication Administration Record (MAR) instead of the TAR. As a result, the nasal spray was not administered on the specified dates. A Certified Medication Aide (CMA) noted the order but did not administer the nasal spray, as it was outside their scope of practice, and informed a nurse, though the specific nurse was not recalled. Interviews with staff revealed a lack of awareness and understanding of the orders, with the Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledging the categorization errors. The nurse practitioner expected the orders to be executed promptly to prevent the spread of illness and ensure timely treatment. The DON admitted to a lapse in educating the new nurse practitioner on the facility's order entry process, which contributed to the errors in order categorization.
Food Safety and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, the facility did not ensure that potato rolls stored in the walk-in refrigerator were labeled with an expiration date. This oversight was noted during an observation on July 9, 2024, at 9:41 AM. The absence of an expiration date on the potato rolls could potentially lead to the use of expired food items, posing a risk of food-borne illness to residents. Additionally, the facility did not ensure that kitchen staff used appropriate hair restraints while preparing and serving food. On July 10, 2024, during the lunch meal service, it was observed that Dietary Aide F and the Assistant Dietary Manager were not wearing hair restraints that fully covered their hair. Dietary Aide F had long braids that were not completely secured under the hair restraint, and the Assistant Dietary Manager had loose strands of hair not properly covered. Both staff members were involved in food preparation and serving tasks, which could lead to hair contamination in the food served to residents. Interviews with the involved staff members revealed an awareness of the requirement for proper hair restraints and food dating, but lapses in adherence to these standards were acknowledged. The Dietary Aide and Assistant Dietary Manager admitted to not fully securing their hair, and the Dietary Manager confirmed the expectation for all kitchen staff to wear hair restraints and date food items appropriately. The facility's policies, as well as the FDA Food Code, emphasize the importance of these practices to prevent cross-contamination and ensure food safety.
Infection Control Deficiencies in Water Management and PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two significant deficiencies. Firstly, the facility did not implement the measures outlined in their Water Management Program policy to prevent the growth of Legionella bacteria in their water system. A review of the facility's monthly water maintenance records for June and July 2024 showed no testing for Legionella bacteria growth. Interviews with the Administrator and the Operational Director confirmed that no water testing had been conducted, despite the risk of Legionella growth in the water system. The facility's Water Management Program, based on CDC and ASHRAE recommendations, was not fully executed, as it lacked testing to ensure the absence of Legionella growth. Secondly, the facility failed to ensure that a Certified Nursing Assistant (CNA) adhered to proper Personal Protective Equipment (PPE) protocols when entering and exiting the room of a resident on isolation precautions for COVID-19. The resident, who was cognitively intact and had multiple health conditions, was on airborne precautions. Despite signage indicating the need for full PPE, the CNA entered the resident's room wearing only a mask and gloves, believing that full PPE was unnecessary for tasks not involving direct care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that staff were expected to wear full PPE as indicated on the signage, but the CNA was unclear about the expectations for non-direct care tasks. The CNA's employee file showed a competency evaluation for isolation care, but the CNA did not recall recent in-services on infection control or isolation precautions. The DON, who also served as the infection preventionist, acknowledged the lapse in PPE protocol and stated that a verbal reminder had been given to staff, although it was not documented. The facility's infection control guidelines required transmission-based precautions whenever more stringent measures than standard precautions were necessary, but these were not followed in this instance.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents, both of whom had unclean and untrimmed fingernails. Resident #66, a male with severe cognitive impairment due to cerebral infarction, required assistance with personal hygiene. His care plan included regular nail care, but observations revealed his nails were long and dirty. Similarly, Resident #80, a male with moderate cognitive impairment and physical limitations, also had long and dirty fingernails despite his care plan specifying regular nail maintenance. Interviews with facility staff, including an LVN and the DON, confirmed that both CNAs and nurses were responsible for nail care, with nurses specifically handling residents with diabetes. The staff acknowledged the risk of infection and skin breakdown due to inadequate nail care. The facility's policy on nail care emphasized daily cleaning and regular trimming to prevent infections, yet these procedures were not followed for the two residents, leading to the identified deficiency.
Failure in Medication Management on Nurses Cart Hall 400
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, specifically in the management of medication carts. During an observation and record review, it was found that the medication cart in Hall 400, managed by LVN B, contained medications in unsecure containers. Specifically, the blister packs for a resident's lorazepam and another resident's tramadol had broken seals with the pills still inside, taped over. This indicates a failure in the procedures for acquiring, receiving, dispensing, and administering drugs, which could lead to drug diversion and residents not receiving the intended therapeutic benefits. Interviews with LVN B and the DON revealed that the facility's protocol required nurses and medication aides to check medication blister packs for broken seals during shift changes. However, LVN B admitted to not checking the blister packs during the count, and the DON confirmed that any broken seal should result in the pill being discarded. The facility's policy on medication labeling and storage also mandates contacting the dispensing pharmacy for instructions on returning or destroying discontinued, outdated, or deteriorated medications. The lack of adherence to these protocols contributed to the deficiency observed.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by State and Federal laws. Specifically, Resident #1's Fluticasone Propionate nasal spray and Trelegy Ellipta inhaler were found on the resident's bedside table instead of being secured in the medication cart or medication room. Resident #1, an elderly female with moderate cognitive impairment, Type 2 diabetes mellitus, and chronic respiratory failure, stated that a nurse had left the medications on her table the previous morning. The resident had not used the medications since they were left there. Interviews with the assigned LVN and the DON confirmed that medications should not be left unsecured in resident rooms. The LVN admitted to not noticing the medications during an earlier visit to the resident's room. The DON stated that no residents in the facility were authorized to self-administer medications and acknowledged the risk of leaving medications in rooms. The facility had previously conducted in-service training on medication administration, emphasizing that medications should not be left in resident rooms. The facility's policy on self-administration of medications also indicated that unauthorized medications found at the bedside should be turned over to the nurse in charge.
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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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Care Communities And Services Mesquite | 1.6 mi | — | 1 | 0 |
| Willowbend Nursing And Rehabilitation Center | 1.7 mi | — | 18 | 0 |
| Palomino Place | 1.9 mi | — | 11 | 0 |
| Edgewood Rehabilitation And Care Center | 2.7 mi | — | 2 | 0 |
| Mesquite Village Wellness & Rehabilitation | 3 mi | — | 0 | 0 |
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