Caremind Homes

The facility failed to implement and document physician orders for weekly blood pressure monitoring for a resident with hypertension. Reviews of the medication administration record and vital signs logs showed no recorded blood pressure readings for the resident during February and March 2025. Additionally, the medication aide reported they had not been instructed to perform these monitoring tasks.

The facility failed to ensure the implementation of weekly blood pressure monitoring for a resident with hypertension as ordered in their FL-2. Review of medication administration records and vital sign logs showed no documented blood pressure entries for the resident during the period of February 2025 through March 2025.

The facility failed to clarify medication orders with a physician or prescribing practitioner when discrepancies were identified. Specifically, for one resident, the facility failed to ensure the FL-2 form accurately reflected the administration of Tresiba, despite the medication being documented in the eMAR and physically present in the home.

The facility failed to contact the resident's physician to clarify medication orders when discrepancies were identified. Specifically, for one resident, the physician's orders (FL-2) omitted the administration of Tresiba, despite the medication being listed on an after-visit summary and being documented as administered in the eMAR.

The facility failed to notify the Division of Health Service Regulation (DHSR) that the evacuation capabilities of three out of four sampled residents had changed. Specifically, the residents' needs no longer matched the evacuation capabilities listed on the facility's license.

The facility failed to properly manage and document changes in resident status/level of care. While the facility contested this regarding Resident #3, the deficiency relates to the oversight of resident changes as noted during the survey period.

The facility failed to administer medications as ordered to one resident regarding a Vitamin D3 supplement. While the resident had an active order for the supplement, there were no entries for the medication in the June or July 2021 MAR, and the medication was unavailable for administration during the survey. The pharmacy confirmed that the facility was responsible for contacting them for refills, which had not been done.

The facility failed to administer prescribed medications as ordered for one resident. Specifically, the resident was not receiving their prescribed Vitamin D3 supplement, and the facility had failed to contact the pharmacy for a refill since January 2021.

The facility failed to administer medications as ordered to one resident regarding a Vitamin D3 supplement. While the resident had an active order for the supplement, there were no entries for the medication in the June or July 2021 MAR, and the medication was unavailable for administration during the survey. The pharmacy confirmed that the facility was responsible for contacting them for refills, which had not been done.