Cadence Garner

The facility failed to provide non-disposable place settings, including silverware and beverage containers, for residents eating meals in their rooms. Observations and interviews revealed that residents were being served meals using plastic utensils and styrofoam or plastic cups instead of the required non-disposable items.

The facility failed to ensure that three out of four exit doors accessible to residents with disorientation or wandering behaviors had audible alarms that activated when opened. Specifically, the front entrance on the assisted living side and the A Hall and D Hall exit doors lacked audible alarm sounds upon opening.

The facility failed to ensure that self-administered medications were stored in a safe and secure manner. Specifically, for two residents, medications were left out on tables in unlocked rooms while the residents were not present, violating the facility's policy to use locked storage and keep rooms locked when residents are away.

The facility failed to ensure that medications for residents who self-administer were stored in a safe and secure manner. Specifically, medications including topical gel and inhalers were found left out on tables in residents' rooms, and resident room doors were left open, violating the policy that medications must be kept in locked storage.

The facility failed to ensure that medications self-administered and stored in a resident's room were kept in a safe and secure manner. Specifically, four medications were found in an unlocked side table drawer and two medications were in a medication cabinet for Resident #3.

The facility failed to ensure that medications self-administered by a resident were stored in a safe and secure manner. Specifically, four medications were found in an unlocked side table drawer and two medications were left in an unlocked bathroom medicine cabinet.

The facility failed to administer medications as ordered for several residents, including incorrect dosages for blood pressure and UTI prevention medications. Specifically, a resident received 5mg of Amlodipine instead of the ordered 10mg. This resulted in a medication error rate of 12% during the observed medication pass.