Garbry Ridge

Based on observations, staff interviews, and policy review, the facility failed to ensure the main kitchen was kept in a clean and sanitary manner. This had the potential to affect all the residents. The facility census was 64.

Findings include:

Observation with interview on 04/24/26 at 10:52 A.M. with Cook #211 revealed the facility's main kitchen had a sink drain which was coated with thick dark brown substance around the walls of the drain. Cook #211 confirmed the sink drain had thick dark brown substance on the walls of the drain. Cook #211 stated it was probably just build-up.

Observation with interview on 04/24/26 at 10:55 A.M. with Cook #201 revealed the grill had grease built up along the side of the grill near the deep fryer and the grease had run down the side of the grill and solidified along the side of the grill. There was grease built up around the tilt skillet that was located on the other side of the deep fryer. Cook #201 confirmed there was grease built up on the side of the grill and down the side of the grill and on the tilt skillet.

Observation with interview on 04/24/26 at 11:00 A.M. with Dietary Manager (DM) #205 revealed there was grease built up on the lower shelves of the steam table across from the deep fryer and grill. Pans for the steam table were resting with the open end on the shelves. DM #205 confirmed the shelves had grease built up and that the pans for the steam table had been placed on the shelves after being cleaned.

Interview on 04/24/26 at 12:35 P.M. with Executive Director confirmed the facility did not have a monthly cleaning log for the kitchen.

Review of the facility policy titled Preventive Maintenance-Nutritional Services

Based on review of the medical record, staff interviews, and policy review, the facility failed to implement fall prevention interventions. This affected one (#06) out of five residents reviewed. The facility census was 64.

Findings include:

Review of the medical record for Resident #06 revealed an admission date of 01/27/20 with medical diagnoses of anemia, chronic kidney disease stage IV, dementia, and anxiety.

Review of the Resident Assessment form dated 12/22/24 indicated Resident #06 exhibits periods of forgetfulness and may wander and required assistance with bathing, transfers, dressing, toileting, and mobility.

Review of the nurse note dated 03/31/25 at 7:23 A.M., documented Resident #06 fell off toilet and sustained mid forehead hematoma and small skin tear. Further review of the notes dated 04/25/25 revealed the root cause analysis was the resident fell off the toilet hitting head and getting a skin tear to right elbow. The note reported the intervention was inappropriate and the Director of Nursing's (DON) intervention was to educate staff not to leave the resident unsupervised on the toilet.

Review of a nurses' note dated 09/21/25 at 9:35 A.M., stated staff assisted Resident #06 into the bathroom and assisted to a sitting position on the toilet with pants down. Staff obtained a dry incontinence brief and washcloths while the resident sat on the toilet. Resident #06 got up, pulled up pants, turned around and sat on the floor of the shower. The note indicated Resident #06's range of motion was within normal limits, was alert with confusion, and staff assisted Resident #06 back onto the toilet again.

Review of the medical record for Resident #06 revealed a nursing post charting note, dated 09/21/25, stated temporary intervention was to not leave Resident #06 alone on the commode.

Review of the nurses' note dated 09/22/25 at 1:53 P.M. stated resident incident note was reviewed, and root cause was resident's cognitive status was limited and Resident #06 was unable to recall to use pendant for assistance and attempted to do things per self. The note stated staff and Resident #06 were educated regarding frequent checks and frequent toileting.

Interview on 11/05/25 at 4:09 P.M. with the Director of Clinical Services (DCS) confirmed staff had left Resident #06 alone on the toilet on 09/21/25 while they left to get supplies and Resident #06 fell out of the toilet. The DCS stated Resident #06 did not sustain any injuries with fall on 09/21/25. The DCS confirmed the fall intervention for Resident #06's fall on 03/31/25 was for staff to not leave Resident #06 unattended while on the toilet.

Review of the facility policy titled, Accidents and Incidents

Based on observation, medical record review, staff interview, review of the medication insert guideline, and policy review, the facility failed to ensure medications were administered per physician orders. This affected one (#53) out of four residents reviewed for medication administration. The facility census was 64.

Findings include:

Review of the medical record for Resident #53 revealed an admission date of 07/10/20 with diagnoses of essential (primary) hypertension, acute on chronic diastolic (congestive) heart failure and presence of aortocoronary bypass graft.

Resident last assessed for self-medication administration on 01/20/24 with staff required to administer medication.

Review of the physician order dated 03/31/24 revealed Resident #53 had an order for metoprolol tartrate (high blood pressure medication) 100 milligram (mg), one tablet twice daily.

Review of the medication administration record for October 2025 and November 2025 revealed metoprolol tartrate 100 mg, one tablet was signed off twice daily as given.

Observation on 11/06/25 at 7:09 A.M. revealed Licensed Practical Nurse (LPN) #266 administered metoprolol succinate 100 mg, one tablet to Resident #53.

Interview on 11/06/25 at 7:32 A.M., with LPN #266 verified Resident #53 was administered metoprolol succinate 100 mg one tablet. Interview also confirmed the physician order was for metoprolol tartrate 100 mg, one tablet. Interview also confirmed the bottle of metoprolol succinate 100 mg was filled on 06/17/25 and that Resident #53 has been administered metoprolol succinate 100 mg twice daily since the medication was refilled on 06/17/25.

Interview on 11/06/25 at 9:03 A.M. with LPN #254 confirmed when Resident #53 returned from a hospital stay on 03/31/24 she had a new order for metoprolol tartrate 100 mg, one tablet twice daily and that the order was not sent to the pharmacy to be filled.

Review of the medication insert guidelines for metoprolol tartrate revealed the medication was an immediate release short acting medication. The medication insert guidelines for metoprolol succinate revealed the medication was an extended release, long acting medication.

Review of the Medication Administration policy, dated 10/17/07 revealed prior to administration, the medication and dosage will be compared to the medication label. If the label and the medication administration record and label do not match, the physician orders will be checked for correct dosage.

Based on review of facility fire drill documents and staff interview, the facility failed to ensure transmission/receipt of fire signal to the appropriate fire department or monitoring station was completed monthly as required. This had the potential to affect all residents residing in the facility. The facility census was 64.

Findings include:

Review of the facility fire drill documents revealed there was no documentation to support the transmission of fire signal or receipt of that signal to the appropriate fire department or monitoring station for fire drills conducted on 03/05/25, 06/27/25, and 09/26/25 during the night shift.

Interview on 11/05/25 at 2:26 P.M., the Maintenance Director #210 stated the fire drills completed on 03/05/25, 06/27/25, and 09/26/25 were completed on third shift and were silent alarms. The Maintenance Director #210 confirmed the facility did not have documentation to support transmission of the fire signal or a receipt of that signal to appropriate fire department or monitoring station within 12 hours of the coded announcements.

This deficiency is a recite to the annual surveys completed 09/06/22 and 02/04/25.