The Heritage of Green Hills Care Center.

“A staff member physically pushed a resident down into a chair, used their foot to barricade the resident from standing, and grabbed the resident's wrist, causing the resident to scream in pain. The resident was not using their required walker at the time.”

“A transportation binder containing resident information was observed on an unattended counter at the nurse's station, accessible to unauthorized persons, violating resident record confidentiality requirements.”

“A bottle of hand sanitizer labeled as poison control contact was found unlocked, unattended, and accessible to residents in the Secured Dementia Care Unit, where residents are assessed as incapable of safely using poisonous materials.”

“A large amount of accumulated lint was observed on the floor behind a clothes dryer in Memory Care and covering the dryer exhaust hose. Additionally, a fabric recliner was stored near a hot water heater in the first-floor mechanical room, creating combustible fire hazards.”

“Resident #3's Initial Medical Evaluation was completed more than 60 days prior to admission, failing to meet the requirement for evaluation within 60 days prior to or 30 days after admission.”

“Residents #3 and #4 were not assessed by a physician, PA, or CRNP regarding their ability to self-administer medications and need for medication reminders, despite having prescription medications (diclofenac gel, foot cream, Bacitracin ointment, anti-itch products, and refresh tears) in their rooms.”

“The medication administration record for Resident #1 indicated Acetaminophen 500 mg, take 2 tablets twice daily, but the medication label instructions stated 1 tablet twice daily, creating a discrepancy in the medication record.”

“Resident #2 was prescribed multiple medications (ICY HOT pain relief cream, ICY HOT MAX lidocaine cream, Medikoff throat lozenges, and Pyridostigmine 60 mg) that were not available in the home, preventing the home from following the prescriber's orders.”

“Poisonous materials (disinfectant cleaning spray) were found stored in an unlocked public bathroom drawer in the Secured Dementia unit, not in original labeled containers and accessible to residents.”

“Weekly menus were not posted one week in advance in the Secured Dementia unit as required.”

“Resident 1's assessment indicated inability to self-administer medications, but unlabeled over-the-counter medications were found in the resident's room.”

“Prescribed medications for Resident 3 and Resident 4 were not available on the medication cart on the dates prescribed, indicating failure to implement safe storage and distribution procedures.”

“Resident 2's Medication Administration Record incorrectly indicated a prescribed medication to be given every 4 hours as needed, when the doctor's order specified every 6 hours as needed.”

“Direct care staff person A did not complete training in medication self-administration, infection control/cleanliness/immobility concerns, personal care needs of the resident, or safe management techniques for training year 2022. Direct care staff person B did not complete any of the required training for training year 2022.”

“Staff person A and staff person B did not receive training in emergency preparedness procedures, resident rights, Older Adult Protective Services Act, Falls and Accident Prevention and new population groups during training year 2022.”

“Bedside mobility devices located in rooms 141, 148, 149, 240, 346, 323 and 340 were not firmly secured to the bed, posing a potential hazard to the residents.”

“The letter to the fire department, dated 7/27/23, indicated that the home's capacity is 87, but the home's actual capacity is 90.”

“A review of the home's fire drill log from 2/23/23 to 9/28/23 indicates that fire drills are being routinely conducted between the 23rd and 28th of the month, rather than on different days of the week and at different times of the day and night.”

“Resident #5's insulin medication pen was not dated when it was opened, therefore it could not be measured when it would expire and was considered an expired medication.”

“Resident #3 was admitted to the home on an unspecified date and the initial assessment was completed greater than 15 days from the date of admission, exceeding the required 15-day timeframe.”

“Residents #2, #3, #4 and #5 use bedside mobility devices, but their Resident Assessment Support Plans do not include the specific need for the device, intended use, risks associated with the device, resident's ability to use the device safely, identification of the specific device to be used, or if a cover is required to meet FDA guidelines.”