Compass Assisted Living Rowan

The facility failed to properly document insulin administration for Resident #3. The eMAR lacked spaces for documenting the site of administration, FSBS values, and the specific amount of insulin administered, resulting in 8 of 8 opportunities where the units administered were not recorded.

The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents. Specifically, errors were identified regarding sliding scale insulin for Resident #3 and the management of antihypertensive medications for Resident #1, where medications were not held as ordered based on systolic blood pressure values.

The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents. Specifically, for Resident #3, the electronic medication administration record (eMAR) lacked spaces to document the site of administration, FSBS values, and the amount of insulin aspart administered. Consequently, there was no documentation of the insulin dose for 8 of 8 opportunities between 07/29/25 and 07/31/25.

The facility failed to ensure physician follow-up and monitoring for a resident's blood pressure as ordered. Specifically, the facility did not check the resident's blood pressure daily before administering blood pressure medication and failed to notify the primary care provider of readings outside the ordered range.

The facility failed to ensure that water was served to each resident at each meal, in addition to other beverages. A new system was implemented to provide water on all meal trays to address this deficiency.

The facility failed to ensure physician follow-up was completed for a resident who had an order for blood pressure checked daily before administering medication. Specifically, the facility did not monitor systolic blood pressure as ordered and failed to hold medication when readings were below the required threshold.

The facility failed to ensure the primary care provider (PCP) was notified regarding a resident's refusal of weekly fingerstick blood sugar (FSBS) checks. Specifically, the resident refused checks multiple times in March and April 2023 without documentation of physician notification. This failure prevented the physician from being aware of the refusals, which could have led to a change in the medical order.

The facility failed to ensure the primary care provider (PCP) was notified regarding a resident's refusal of weekly fingerstick blood sugar (FSBS) checks. Specifically, the resident refused multiple weekly checks throughout March and April 2023 without any documentation of physician notification. The resident's PCP stated she was unaware of these repeated refusals and would have wanted to be notified.

The facility failed to ensure primary care provider notification for residents with fingerstick blood sugar values outside of ordered parameters and missed laboratory work for a magnesium level. Additionally, the facility failed to notify physicians regarding residents with multiple medication refusals as required by policy.

The facility failed to ensure primary care provider notification for three residents who had fingerstick blood sugar (FSBS) values outside of ordered parameters, and failed to follow up on a laboratory work order for a magnesium level. Additionally, the facility failed to notify physicians regarding multiple medication refusals for two residents.