Terrabella Fuquay-Varina

The facility failed to provide adequate supervision for a resident with Alzheimer's Disease, resulting in the resident eloping from the facility without staff knowledge. This failure was inconsistent with the resident's assessed needs, care plan, and the facility's own policies regarding community rounds and resident monitoring.

The facility failed to provide supervision in accordance with a resident's assessed needs and facility policy. Specifically, a resident with a diagnosis of Alzheimer's Disease and a known wandering risk eloped from the facility without staff knowledge.

The facility failed to clarify medication orders with a physician for a resident with dysphagia. Specifically, the facility did not verify or document instructions regarding crushing medications in puree, despite handwritten orders from a rehabilitation hospital indicating this requirement.

The facility failed to clarify medication orders for a resident with dysphagia regarding whether medications should be crushed. While a rehabilitation hospital provider had handwritten an order for 'meds crushed in puree,' the facility's diet order sheet and physician orders lacked documentation to confirm this instruction. Consequently, the medication aide administered medications without crushing them during a medication pass.

The facility failed to provide adequate supervision for a resident with extreme confusion, memory loss, and judgment impairment. As a result, the resident eloped into a city street three times within a three-day period.

The facility failed to provide adequate supervision for a resident with advanced dementia, resulting in the resident eloping into a city street three times within three days. Staff failed to review medical documentation and progress notes, leaving them unaware of the resident's severe confusion and high risk for elopement.

The facility failed to provide adequate supervision in accordance with a resident's assessed needs and care plan. Specifically, a resident with advanced dementia and disorientation eloped into city street areas without the facility's knowledge.

The facility failed to provide adequate supervision for a resident with advanced dementia and Alzheimer's Disease, resulting in the resident eloping into city street areas without the facility's knowledge. The facility relied solely on the SLUMS test for placement decisions and failed to adjust supervision based on the resident's changing clinical needs and disorientation.