Clara's Cottage # 1

The facility failed to ensure proper referral and follow-up with the primary care provider for a resident regarding the withholding of insulin. Staff were withholding prescribed Lantus insulin doses based on finger stick blood sugar readings without having physician-ordered parameters for when to hold the medication.

The facility failed to ensure proper referral and follow-up with the primary care provider for a resident regarding the withholding of insulin. Staff were withholding prescribed Lantus insulin doses based on finger stick blood sugar readings without physician-ordered parameters for when to hold the medication.

The facility failed to provide sufficient bedrooms to meet the needs of all occupants, as a live-in non-resident was occupying a designated resident room. A family member of the Administrator was sleeping in the sixth licensed bed, making that bed unavailable for a prospective resident admission.

The facility failed to secure hazardous substances in locked areas, leaving mouthwash, povidone iodine, household chemicals, and petroleum products accessible in common bathrooms, on the front porch, and outside a storage shed. This is a significant risk as one resident in the facility has a diagnosis of dementia.

The facility failed to provide sufficient bedrooms to meet the needs of its licensed capacity because a family member was occupying a designated resident room. This prevented the 6th licensed bed from being available for prospective resident admission.

The facility Administrator failed to maintain responsibility for the total operation of the facility and failed to ensure systems were in place to identify noncompliance regarding resident rights, medication administration, and pharmaceutical care. Specifically, the Administrator was unaware of the theft of resident records and medications, including narcotics, by former supervisors.