Mcgivney Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF760Sep 22, 2023

  Based on interview and record review, the facility failed to ensure a resident received the correct medication for 1 of 1 resident reviewed for a significant medication error. (Resident 20) Resident 20 required an intensive care stay in the hospital for 5 days. Finding includes: The record for Resident 20 was reviewed on 9/19/23 at 2:01 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbance, bradycardia, abnormal weight loss, mood disorder, chronic pain syndrome, and hypertension. A progress note, dated 6/30/23 at 9:25 am, indicated the resident was noted to be lethargic. The skin was cool to touch, he had increased slurring speech, and his speech was garbled. The provider was notified and requested a transfer to the emergency department. […]

• No harm, potential for more than minimal, widespreadF628Aug 21, 2026

  Based on interview and record review, the facility failed to notify the Ombudsman of residents' transfer and discharges with the reason and destination of the transfer and to provide a guardian/responsible party with the notification of the bed hold policy for 10 of 10 residents reviewed for discharge process. (Resident B, C, D, E, F, G, H, J, K and L)Findings include: An email from the State Long Term Care Ombudsman, dated 8/19/26 at 10:43 a.m., indicated the facility had not reported any acute transfers or discharges since 10/13/25. 1. The clinical record for Resident B was reviewed on 8/18/26 at 10:02 a.m. […]

• No harm, potential for more than minimal, widespreadF809Sep 22, 2023

  Based on interview and record review, the facility failed to ensure residents were offered bedtime snacks each evening. There was a 15-hour time lapse between the supper meal and breakfast. This deficient practice had the potential to affect 35 of 35 residents who resided in the facility. Finding includes: A dining schedule, provided at entrance, indicated the facility supper time was 5:00 p.m., and breakfast was at 8:00 a.m., which was a 15-hour time lapse between these meals. During an interview, on 9/20/23 at 11:00 a.m., CNA 10 indicated the cook on the evening shift would gather a cart of snacks including peanut butter and jelly sandwiches and crackers. The facility staff did not pass out the snacks although they were available for any resident who wanted them. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2023

  Based on observation, interview and record review, the facility failed to thaw out meat safely and have the sanitizing solution (used to disinfect tables and counters) bucket levels at the recommended range to kill bacteria. This deficient practice had the potential to affect 35 of 35 residents who received food from the kitchen. Findings include: During the kitchen observation, on 9/17/23 at 11:00 a.m., with the Dietary Staff 19 the following were observed: a. The sink contained 2 large plastic bags of frozen chicken. The sink had no cold water in the sink and the chicken was thawing at room temp. b. The red sanitizer bucket was tested three times. Dietary Staff 19 placed a test strip into the bucket and the testing strip did not change colors. […]

• No harm, potential for more than minimal, widespreadF727Sep 27, 2022

  Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was on site for 8 hours a day for 60 of 63 days from July 27, 2022 to September 27, 2022. This deficient practice had the potential to effect 34 of 34 residents residing in the facility. Finding includes: During the Entrance Conference, on 09/26/22 at 9:56 a.m., the Executive Director indicated the facility had not had a Director of Nursing since July 2022, when the Director of Nursing was terminated. The facility had a RN but the nurse was injured about two (2) weeks ago and had not been in the facility. The registered nurse was PRN (as needed), not a full time employee. […]