Cape Point Memory Care Unit

The facility failed to provide adequate supervision for a resident with dementia, resulting in the resident eloping from the facility in a staff member's vehicle. The resident was later located by law enforcement five miles away from the facility.

The facility failed to ensure that resident rights were maintained and exercised without hindrance, as noted under the standard deficiency finding.

The facility failed to provide a matching therapeutic diet menu for physician-ordered diets to guide food service staff. Specifically, for two residents ordered to be on a low-sodium diet, no low-sodium menu was available, resulting in the service of inappropriate foods like bacon. Staff members, including the cook and supervisor, demonstrated a lack of awareness regarding the requirement for specific therapeutic menus.

The facility failed to maintain a matching therapeutic diet menu for physician-ordered diets to guide food service staff. Specifically, for 2 of 5 sampled residents, there was no low-sodium diet menu available, making it impossible to ensure appropriate meal service for residents with medical needs like hypertension.

The facility failed to ensure that all exit door locks were easily operable by a single hand motion from the inside without keys. Specifically, one of two exit doors on the back hall was found to be non-compliant, which could prevent residents from exiting the facility during an emergency.

The facility failed to ensure all exit door locks were easily operable by a single hand motion from the inside without keys. Specifically, a solid wooden door on the screened-in porch was equipped with a keyed deadbolt that required a key to unlock from both sides, preventing residents from exiting to the backyard during an emergency.

The facility failed to administer medications as ordered for one resident. Specifically, while the resident had an order for two tablets of calcium carbonate daily, the medication administration record only documented the administration of a single 500mg tablet daily.

The facility failed to administer medications as ordered for one resident. Specifically, a change in the dosage of calcium carbonate from one tablet daily to two tablets daily was not updated on the Medication Administration Record (MAR). As a result, the resident was receiving an incorrect dose of the medication.

The facility failed to ensure that residents have a TB test completed upon admission and a second step completed within 30 days of admission.

The Administrator and SCU Supervisor failed to implement a process to review all resident charts to ensure all physician's orders have been followed up on monthly.

The facility failed to conduct monthly reviews of resident charts to ensure that all medication and treatment orders have been implemented.

The facility failed to maintain scheduled monthly extermination services for assessments and treatments.

The SCU Supervisor failed to perform monthly audits of the medication cart, resident charts, and MARs to ensure medication and treatment orders are in place and followed through.