Memory Care of the Triad

The facility failed to serve therapeutic diets as ordered for 2 of 5 sampled residents. Specifically, a resident ordered to be on a pureed diet was served non-pureed chicken and whole oatmeal, and was also served bacon which was not permitted on the prescribed diet.

The facility failed to serve therapeutic diets as ordered for 2 of 5 sampled residents. Specifically, a resident ordered to receive a pureed diet was served non-pureed chicken because the cook was in a rush and failed to use the blender.

The facility failed to maintain matching therapeutic diet menus for 11 residents with physician-ordered diets, such as pureed, mechanical soft, and no concentrated sweets. The facility relied on a single regular menu and did not provide specific guidance for modified diets to food service staff.

The facility failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets for 1 of 4 sampled residents. Specifically, the facility's records did not reflect a recent hospital discharge recommendation for a controlled carbohydrates, heart-healthy diet for Resident #4.

The facility failed to maintain matching therapeutic diet menus for 11 residents with physician-ordered therapeutic diets. While the facility had orders for no concentrated sweets, pureed, and mechanical soft diets, the menus provided by the food provider only covered regular and no added salt diets. Consequently, staff lacked written guidance for preparing specific therapeutic diet extensions.

The facility failed to ensure that 2 of 2 sampled medication aides had completed the required 5, 10, or 15-hour medication training or provided proper verification of previous employment. Specifically, one staff member lacked documentation of required training and had incomplete employment verification records.

The facility failed to keep walls, ceilings, floors, and fixtures clean and in good repair. Observations revealed accumulated dust on air vents and ceiling fans, black substances and debris in floor corners and wall thresholds, and dirty grout in the resident common bathroom shower. Additionally, cleaning supplies were left improperly stored in the dining area, and trash cans were overflowing with debris.

The facility failed to maintain clean walls, floors, and ceilings throughout the dining room, hallways, and common areas. Specific issues included overflowing trash, accumulated dirt and food debris in wall corners, and thick dust on ceiling vents and fans. Additionally, unidentified black substances and marks were observed on dining room walls and floor corners.

The facility failed to provide adequate supervision for residents in accordance with their assessed needs and care plans. Specifically, three out of five sampled residents who were disoriented and semi-ambulatory experienced repeated falls resulting in serious injuries, including a broken elbow, a subdural hematoma, and a broken wrist.