The Gardens of Green Ridge.

“Strong smell of urine detected in hallway near resident rooms and inside resident rooms during inspection, indicating inadequate sanitary conditions.”

“Fire exit door from hall 200 was obstructed by a bedframe placed behind the door, creating a potential egress hazard.”

“The staff training plan for the training year 2026 does not include the dates the training is projected to be completed.”

“Emergency telephone numbers including the nearest hospital and fire department were not posted on or by the telephone in a resident room.”

“A pharmacy label for a resident's eye drop medication indicated to instill two drops into each eye at bedtime, but the physician order specified only one drop at bedtime.”

“A medication administration record listed "Iron" instead of the proper medication name "Ferrous Sulfate" for a resident prescribed a 325mg tablet, creating a discrepancy between the medication label and the administration record.”

“A resident's written initial assessment did not identify the home health agency and contact information for monthly catheter changes that the resident requires as a supplemental health care service.”

“Menus stating specific food being served at each meal were not posted in the Memory Care Unit. Weekly menus must be prepared one week in advance and posted in a conspicuous public place.”

“Resident #1's support plan did not document specific details about the bed enabler device being used, including the need for the device, intended use, associated risks, resident's ability to use it safely, the specific device model, and FDA guideline cover requirements.”

“Support plans for Resident #2 and Resident #3 were not signed by the residents, and there was no notation that residents did not want to participate or were unable to sign as required.”

“A resident experienced a choking episode and was ordered to receive a mechanical soft diet and Speech Therapy evaluation. As of the inspection date, the resident had not received a Speech Therapy evaluation nor had one been scheduled, resulting in failure to follow the prescriber's orders.”

“Resident #1 suffered a fall resulting in a left femur fracture. Emergency services (911) were not called; instead, staff called a private ambulance company directly and had to call multiple times while the resident expressed extreme pain. Additionally, resident #2 pushed resident #3 to the floor and grabbed and yelled at resident #4 in the secure care unit.”

“Resident #2 was involved in aggressive acts against two other residents on 7/5/2024. The home did not update resident #2's assessment support plan after the incidents with a plan to address the resident's behaviors.”

“An unlabeled 24 oz. spray bottle of pine cleaner was found in an unlocked file cabinet in the SCU medication room. The cleaner had been transferred from a one-gallon container into the spray bottle without proper labeling.”

“An unlabeled 24 oz. spray bottle of pine cleaner, an 18 oz. spray bottle of Spic and Span cleaner, and a one-gallon jug of Value Plus Pine Cleaner were found in an unlocked file cabinet in the SCU medication room. The labeled containers indicated the contents were harmful to humans and animals with poison control warnings. The room was unattended by staff.”

“A bag of Toasted Oats cereal located in the SCU pantry was not properly sealed.”

“A bag of Rice Krispies in the SCU pantry was not labeled or dated. Two ice cream sandwiches in the SCU pantry freezer were removed from original packaging and not labeled or dated. A clear bag of frozen manicotti in the walk-in freezer of the main kitchen was not labeled or dated.”

“A handful of lint was noted in the home's laundry room exterior vent. A small amount of lint was noted behind the clothes dryer in the home's laundry room. Combustible and flammable materials may not be located near heat sources or hot water heaters.”

“The 'Resident Information Sheet' in resident #1's blue contract folder was missing health information. This document is used as a transfer sheet when sending residents out for medical care.”

“Resident Room #205 contained OTC medications and syringes that were not locked. The resident in this room does not have an order for these products nor does this resident have an order to self-medicate from their PCP.”