Terrabella Cramer Mountain

The facility failed to properly conduct resident assessments following a significant change in baseline condition. Specifically, the facility must monitor residents for no more than 10 days after identifying a change and complete a new assessment within three days of determining a significant change has occurred.

The facility failed to ensure medications were administered as prescribed for 3 of 5 sampled residents. Specifically, for Resident #1, the facility failed to administer the correct dose of Novolog insulin sliding scale based on finger stick blood sugar readings on multiple dates in April, May, and June 2024.

The facility failed to ensure medications were administered as prescribed for 3 of 5 sampled residents. Specifically, for Resident #1, the facility failed to administer prescribed Novolog insulin doses based on sliding scale blood sugar readings on multiple dates in April and May 2024.

The facility failed to ensure therapeutic diets were served as ordered for 2 of 6 sampled residents. Specifically, there were discrepancies regarding nectar thick liquid and mechanical soft diet orders, including an outdated diet order board and a lack of specific menus for thickened liquids.

The facility failed to ensure that 4 out of 4 sampled medication aides had completed required training on the care of diabetic residents prior to administering insulin and performing blood glucose monitoring. Personnel records for these staff members lacked documentation of the necessary training, and interviews confirmed that some staff had not received diabetic care training during their orientation at the facility.

The facility failed to ensure that medication aides completed required training on the care of diabetic residents prior to administering insulin. Specifically, four out of four sampled medication aides were found to have administered insulin and performed blood glucose monitoring without documented training at the facility.

The facility failed to notify a physician when a resident missed their prescribed dose of Coumadin for three consecutive days. This failure prevented the physician from being informed of a significant medication non-compliance regarding an anticoagulant. Consequently, the facility did not meet the requirement to assure referral and follow-up for the resident's acute health care needs.