Terrabella Indian Trail

The facility failed to provide necessary medical assistance for a resident with dementia who experienced abdominal and back pain following an unwitnessed fall and mishandling by staff. Clinical records and EMS reports indicated the resident suffered multiple rib fractures and a small hemothorax, yet the facility failed to ensure appropriate follow-up and communication regarding the incident.

The facility failed to provide necessary medical follow-up and communication for a resident with dementia who experienced an unwitnessed fall and subsequent rib fractures. Specifically, the facility failed to report the fall and the resident's ongoing abdominal and back pain to the medical provider, and provided inaccurate information to the resident's responsible party regarding the nature of the fall.

The facility failed to maintain hot water temperatures in residents' rooms between 100 and 116 degrees Fahrenheit. Observations across the Assisted Living hall and Special Care Unit revealed multiple bathroom sinks with temperatures ranging from 112.5 to 118.4 degrees Fahrenheit.

The facility failed to maintain hot water temperatures in residents' rooms between 100 and 116 degrees Fahrenheit. Inspections revealed multiple bathroom sinks with temperatures ranging from 112.5 to 118.4 degrees Fahrenheit. Additionally, the facility lacked complete water temperature logs for March 2024.

The facility failed to lock four exit doors accessible to residents in the Special Care Unit (SCU). Specifically, one exit door was not equipped with a sounding device to alert staff when opened, which contributed to a resident with wandering history eloping from the facility.

The facility failed to provide adequate supervision for a resident with disorientation and wandering behaviors. This lack of supervision allowed the resident to elope through an unlocked SCU door without staff knowledge, resulting in the resident being found walking in a busy roadway.

The facility failed to equip all accessible exit doors with a sounding device for residents known to be wanderers. Specifically, one exit door in the Special Care Unit (SCU) lacked a device that activates when opened, which contributed to a resident eloping.

The facility failed to provide adequate supervision to a resident with a history of wandering and disorientation. This lack of supervision allowed the resident to elope from the facility through an unlocked SCU door without staff knowledge.

The facility failed to notify the primary care provider (PCP) regarding a significantly high blood pressure result and a seizure accompanied by a fall for a resident. Specifically, staff failed to report a seizure and fall that occurred on 04/09/23 to hospice or the PCP, resulting in a delay in medical evaluation until the following day.

The facility failed to ensure proper referral and follow-up for a resident's acute health needs. Specifically, the facility failed to notify the primary care provider regarding a significantly high blood pressure result and a seizure accompanied by a fall. Additionally, there was no documentation of care or interventions provided following the reported seizure and fall.