Terrabella Durham

The facility failed to ensure medications were administered as ordered by a licensed practitioner for two residents. Specifically, Resident #1 did not receive prescribed fentanyl patches as ordered between June 22 and June 30, 2025, and again between July 1 and July 3, 2025.

The facility failed to ensure that 8 ounces of milk or equivalent dairy products were served three times daily to residents in the Assisted Living and Special Care Units. Menu reviews and meal observations revealed that milk and dairy items were frequently omitted from breakfast, lunch, and dinner services.

The facility failed to ensure that 8 ounces of milk or equivalent dairy products were served three times daily to residents in the Assisted Living and Special Care Units. A review of menus for January 21 and 22, 2025, showed that milk was not listed for breakfast, lunch, or dinner, and no equivalent dairy products were provided.

The Dining Director or designee failed to ensure the posted therapeutic menu was checked daily. The facility is required to implement a monitoring process for 30 days to ensure compliance.

The facility failed to implement physician orders for finger stick blood sugar (FSBS) checks three times daily for 2 of 5 sampled residents. Specifically, for Resident #4, documentation showed FSBS checks were only being performed once daily and lacked required results for most of August 2023.

The facility failed to provide a safe and orderly discharge for Resident #6, who was discharged without proper notification. Specifically, the facility failed to follow required protocols for notifying the county department of social services and providing necessary documentation to the new caregiver during the discharge process.

The facility failed to provide a safe and orderly discharge for one sampled resident. Specifically, Resident #6 was discharged without providing the required proper notification.

The facility failed to ensure timely health care referral and follow-up for a resident following an unwitnessed fall. Specifically, staff failed to contact emergency medical services (EMS) promptly after the resident reported significant pain, resulting in a delayed hospital transfer for a pelvic fracture.