Morningstar Assisted Living

The facility failed to ensure health care referral and follow-up was completed for two residents. Specifically, the facility did not complete a speech therapy evaluation referral following a choking incident for one resident and failed to ensure PT/INR lab results were faxed to the primary care provider for another.

The facility failed to ensure health care referral and follow-up was completed for two residents. Specifically, for Resident #1, the facility failed to follow up on a speech therapy evaluation order following a choking incident, and failed to document PCP notification for a subsequent choking incident.

The facility failed to administer medications as ordered by the Primary Care Provider for one of five sampled residents. Specifically, conflicting orders were found for Depakote ER, with one order for 250mg and another for 1500mg total per morning.

The facility failed to administer medications as ordered by the Primary Care Provider for Resident #4. Specifically, the facility failed to administer and document a 250mg dose of Depakote ER scheduled for 2:00pm daily, as evidenced by the resident's physician orders and eMAR records for March and April 2022.

The facility failed to ensure medications were administered as ordered for 3 of 6 sampled residents. Specifically, for Resident #2, a 90-day supply of terbinafine was not available because a refill was never requested after the initial 30-day supply was exhausted.

The facility failed to ensure medications were administered as ordered for 3 of 6 sampled residents. Specifically, for Resident #2, the facility failed to provide a continuous supply of terbinafine despite orders for a 90-day course, resulting in the medication being unavailable by late January 2022.