Americares Adult Homes #3

The facility failed to ensure the breakfast meal met the required menu standards. On 09/10/25, residents were served only cereal, a banana, and juice/coffee instead of the posted menu of sausage, gravy, biscuits, eggs, and fruit. Although ingredients like biscuits and eggs were available in the kitchen, the staff served a simplified meal because it was quicker to prepare.

The facility failed to ensure the breakfast meal met the posted menu requirements. Although ingredients like biscuits and sausage were available in the kitchen, staff served only cereal, bananas, and juice to residents because it was a quicker option.

The facility failed to ensure proper health care coordination and follow-up for a resident. Specifically, the facility did not notify the primary care provider regarding the resident's alcohol use or an incident involving staff-inflicted injury, and failed to coordinate necessary mental health services and medication management.

The facility failed to ensure health care coordination and follow-up for a resident, including failing to notify the primary care provider of the resident drinking alcohol and an incident where the resident was handcuffed and injured by staff. Additionally, the facility failed to coordinate mental health services for the management of medications and therapy for the resident's diagnoses.

The facility failed to ensure medication administration records (MAR) were accurate for one of three sampled residents. Specifically, the record for resident #17 included inaccurate documentation regarding the administration of medication used to treat low blood sugar.

The facility failed to maintain hot water temperatures at a minimum of 100 degrees F at a resident's bathroom sink, which was measured at 84.1 degrees F. Additionally, the sink had a minimal trickle of water and a leak in the hot water pipe that had resulted in water collecting in a waste basket under the sink for several months.

The facility failed to ensure that medication administration was documented accurately. Specifically, there was no record of the administration of certain medications, and the facility failed to maintain a complete medication administration record.

The facility failed to ensure that medications were administered according to the prescribed instructions. There were instances where medications were not administered at the correct time or in the correct dosage as required.

The facility failed to maintain proper documentation for medication changes. There was no evidence that the facility updated the medication administration records following changes in physician orders.

The facility failed to ensure that all medications were properly labeled and stored. Some medications were found without clear identification or were stored in a manner that did not meet safety standards.

The facility failed to monitor residents for adverse reactions to medications. There was no documented evidence that the facility was assessing residents for side effects or changes in condition following new medication regimens.

The facility failed to notify the primary care provider (PCP) for a resident with fingerstick blood sugar readings greater than 450, despite physician orders to do so. Specifically, there was no documentation of notification for high readings recorded on 11/24/2019 and 01/13/2020. Staff interviews indicated a breakdown in the communication process between medication aides and the Resident Care Director regarding critical blood sugar levels.