Best of Care

The facility failed to maintain matching therapeutic diet menus for food service guidance. Specifically, for one resident ordered to have a regular diet with ground meats, no therapeutic menu was available to guide staff. This lack of guidance meant it could not be determined if the resident was being served the correct therapeutic diet.

The facility failed to maintain matching therapeutic diet menus for physician-ordered diets to guide food service staff. Specifically, for one resident ordered a regular diet with ground meats, no corresponding therapeutic menu was available in the kitchen. This lack of guidance meant staff could not verify if the resident was being served the correct prescribed diet.

The facility failed to ensure medications were administered according to physician orders and manufacturer instructions. Specifically, a medication aide attempted to administer undiluted potassium chloride liquid to a resident without following the manufacturer's instruction to dissolve the medication in water first.

The facility failed to ensure medications were administered as ordered for one resident during the morning medication pass. Specifically, errors were identified regarding a potassium supplement and a proton-pump inhibitor medication, resulting in an 8% medication error rate.

The facility failed to provide complete table settings consisting of a knife, fork, spoon, plate, and beverage containers. During a lunch service observation, multiple residents were observed using their fingers or spoons to cut meat because no knives were provided at the tables.

The facility failed to ensure mealtime table service included a complete place setting consisting of a knife, fork, and spoon. During a lunch service observation, multiple residents were unable to cut their chicken breast because no knives were provided at the tables, forcing some residents to use their hands or forks to tear the meat.

The facility failed to ensure necessary follow-up for a resident's acute health care needs. Specifically, the facility failed to obtain ordered laboratory tests for Vitamin B12 and Vitamin D levels, as the laboratory request was overlooked by management.

The facility failed to ensure necessary follow-up for a resident's acute health care needs. Specifically, the facility failed to obtain a required vitamin B 12 laboratory test as ordered by the provider.