Fleet Landing

In the surveyor’s words

From the most serious findings on record at Fleet Landing, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF677Jul 24, 2025

  Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that two (Residents #31 and #32) of two residents reviewed for activities of daily living (ADLs), from a total survey sample of 21 residents, received necessary services to maintain good grooming and hygiene, specifically fingernail care, when they were unable to complete ADLs independently. The findings include: 1.On 07/21/2025 at 11:40 am, Resident #31 was observed lying in bed. Her fingernails on both hands were elongated with brown debris under each of the nails. The resident was asked if she preferred her nails long. She stated, No, I like them trimmed. […]

• No harm, potential for more than minimal, isolatedF689Jul 24, 2025

  Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that the resident environment remained free of accident hazards for one (Resident #32) of two residents reviewed for accident hazards, from a total survey sample of 21 residents.The findings include:On 07/21/20 25 at 11:41am, a tube of Voltaren Arthritis Pain (diclofenac sodium) topical gel 1% was observed in the bathroom on a side table, next to the toilet of Resident #32. (Photographic evidence obtained) An interview was attempted with Resident #32 at that time; however, he was unable to answer any questions related to the Voltaren tube observed. […]

• No harm, potential for more than minimal, isolatedF583Aug 3, 2023

  Based on observation, record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #1) of two residents observed during medication administration. Resident #1 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). The findings include: On 8/2/23 at 1:00 p.m., Licensed Practical Nurse B was observed preparing medications for Resident #1. A review of the resident's medication orders revealed that all her medications were administered through her gastrostomy tube (feeding tube). LPN B was observed administering two medications through the gastrostomy tube to Resident #1. […]

• No harm, potential for more than minimal, isolatedF658Aug 3, 2023

  Based on observation, record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #30) of two residents observed during administration of medication. Medication orders were not verified prior to twice attempted administration of medicated eye drops in the resident's wrong eye. The findings include: On 8/1/23 at 9:33 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #30. A review of the resident's medication orders revealed the following: Pilocarpine (medication used for treatment of glaucoma and ocular hypertension) 1% eye drops: Administer one drop to right eye twice a day. […]