Gordon Lane Care Center

In the surveyor’s words

From the most serious findings on record at Gordon Lane Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Apr 12, 2024

  Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to ensure the drugs and biologicals were stored in a safe manner when: * One of two medication rooms (Medication Room A) had one opened, unsealed package of IV Statlock PICC Plus (a device to secure an IV catheter from kinking which could lead to blockage of fluids going through the vein). * The facility's Central Supply Room was observed to contain artificial tears, earwax softener drops, dry eye relief, muscle rub cream, and enema bottles stored on the same shelf next to the oral medications such as calcium, omeprazole, sodium chloride, and fish oil. […]

• No harm, potential for more than minimal, patternF812Apr 12, 2024

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the proper disposal, labeling and dating of foods in the kitchen. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the countertop can opener was free from brownish, whitish, and grayish discoloration. * The facility failed to ensure the stainless mixing bowls, knives, and water pitchers were rinsed prior to use. * The facility failed to ensure one knife and blender were air dried prior to use. * The facility failed to ensure a clean spatula was placed on top of an unsanitized preparation area. […]

• No harm, potential for more than minimal, patternF880Apr 12, 2024

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed. * LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date. * LVN 1 placed the spoons directly on the bedside table and used the spoons to stir the medications prior to administering medications. * LVN 1 placed the piston syringe and plunger used for G-tube medication administration directly on the bedside table surface without a barrier. […]

• No harm, potential for more than minimal, patternF919Apr 12, 2024

  Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' call light system was fully functional as evidenced by: * The call light system for two of two nursing stations were not audible. * Resident 67's call light was not answered promptly. These failures posed the risk of staff not responding promptly to residents in need of immediate assistance. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22, showed the staff members who see or hear an activated call light were responsible for responding. If the staff member could not provide what the resident desired, the appropriate personnel should be notified. 1. On 4/9/24 at 1408 hours, Resident 61's call light was observed on but not audible. […]

• No harm, potential for more than minimal, patternF755Oct 2, 2023

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure the controlled medications signed out of the controlled drug records were administered and documented on the MAR for four of six sampled residents (Residents 1, 2, 3, and 4). In addition, Resident 2's pain medication was signed out on the controlled drug record two hours apart on 9/12/23 at 1400 and 1600 hours, instead of every four hours as ordered by the physician. These failures had the potential to result in controlled medications abuse or diversion and poor health outcomes to the residents. […]