Dedove Homes @ Chalk Level Road

The Administrator failed to consistently review fire drill logs. The facility has implemented a plan to review these logs every two months.

The Administrator failed to adequately monitor residents for changes in needs or coordinate with physicians. The facility will now observe residents and attend appointments at least every six months.

Resident records were not being checked regularly for required TB test information. The Administrator will now check resident records once a month for this data.

The facility failed to monitor the MAR for medication refusals. The Administrator will now monitor the MAR for refusals on a monthly basis.

The facility failed to monitor substitution logs. The Administrator will now check these logs once per month.

The facility failed to ensure residents were receiving snacks three times a day. The Administrator will now interview residents monthly to verify snack frequency.

The facility failed to ensure residents were receiving fruit twice a day and milk three times a day. The Administrator will now conduct monthly checks to verify these nutritional offerings.

The facility failed to monitor the adequacy of laundry and housekeeping services. The Administrator will now interview residents monthly regarding these services.

The facility failed to properly reconcile the MAR with the actual medications present for residents. The Administrator will now check the MAR and medications twice a month.

The facility failed to ensure that the MAR and medications were checked to confirm a resident's capability for self-administration. This check will now occur twice a month.

The facility failed to ensure that scheduled II medications were stored under double lock. The Administrator is now checking to ensure compliance.

The facility failed to ensure that 2 of 2 exit doors had an audible sounding device that activates when opened. This is required for residents who are disoriented or exhibit wandering behavior. Observations showed the front door produced no sound when opened and a side door remained open over an inch throughout the day.

The facility failed to administer medication as ordered for one resident. Specifically, the medication administration record showed that a scheduled 2:00pm dose of ibuprofen was not documented for the period of 08/16/24 to 08/31/24, despite orders requiring administration every 8 hours.

The facility failed to administer medication as ordered for one resident, specifically failing to follow a change from scheduled to PRN (as needed) dosing for ibuprofen. Additionally, the medication aide failed to document the 2:00pm dose for the resident's scheduled medication.

The facility failed to ensure that controlled medications were stored under double lock for two sampled residents. While the medication closet door was locked, there was no locked box inside the closet to provide the required double-locking mechanism for narcotics.