Elizur Family Care Home

The facility failed to ensure medication administration records were accurate for 2 of 3 sampled residents. Specifically, for Resident #1, there was no documentation of finger stick blood sugar (FSBS) or Humulin insulin units administered throughout March 2026, despite active orders for these treatments.

The facility failed to ensure medications were administered as ordered for a resident. Specifically, the facility continued to document the administration of carvedilol on the MAR despite the medication being out of stock since July 2024. Staff failed to notice the missing medication in weekly dose packs or follow up with the pharmacy or provider regarding the expired order.

The facility failed to ensure medications were administered as ordered for one resident. While physician orders were updated to increase carvedilol dosage, the medication administration records (MAR) continued to reflect the old dosage, and the resident was found to have no medication on hand for administration.

The facility failed to conduct the required at least four fire evacuation rehearsals annually. Records showed no fire drills had been completed since September 2022, missing the required quarterly frequency.

The facility failed to ensure that one of three sampled residents had an assessment and care plan updated annually. This includes the requirement to assess functional status, psychosocial well-being, and cognitive status.

The facility failed to conduct the required minimum of four fire evacuation plan rehearsals annually. Records review showed that no fire drills had been documented since September 2, 2022, prior to the survey date.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, sertraline 50mg for depression and ketoconazole 2% shampoo were not documented as administered and were unavailable for use because the orders had not been properly faxed to the pharmacy.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, there was no documentation of sertraline 50mg being administered between April 1, 2021, and June 30, 2021, and the medication was not available on hand at the time of the survey. The pharmacy also confirmed they had not received the order to dispense this medication.

The facility failed to maintain clean and well-repaired walls, ceilings, and floors. Specific issues included missing paint, stains, and dirt buildup on walls, door frames, and baseboards in the dining room and hallways. Additionally, floor surfaces showed scratches, marks, and dark stains.