Terrabella Little Avenue

The facility failed to provide adequate supervision for a resident with a history of wandering behaviors in the Special Care Unit, which resulted in the resident eloping from the facility. Despite documented exit-seeking behaviors and a high risk for elopement, the resident was found in the parking lot after exiting through an emergency door.

The facility failed to provide adequate supervision for a resident with a history of wandering behaviors in the Special Care Unit, which resulted in the resident eloping from the facility. Observations of the unit revealed multiple emergency exit doors that led to the outside or parking areas, and staff failed to respond to alarms in a manner that prevented the elopement.

The facility failed to ensure proper referral and follow-up for a resident's healthcare needs. Specifically, staff failed to document notification to the Primary Care Provider when the resident's finger stick blood sugar readings exceeded the ordered threshold of 401 on multiple occasions between November 2024 and January 2025.

The facility failed to ensure medications were administered as ordered for one of five sampled residents. The record review indicated a failure to follow physician orders regarding medication administration related to blood sugar management.

The facility failed to ensure referral and follow-up to meet routine healthcare needs for one resident. Specifically, there were multiple instances between November 2024 and January 2025 where the resident's finger stick blood sugar was 401 or greater, but there was no documentation that the Primary Care Provider was notified as ordered.

The facility failed to provide adequate supervision for a resident with a history of wandering behaviors in the Special Care Unit. Specifically, the resident was allowed access to an unlocked and disarmed outside exit door, which resulted in the resident eloping from the facility.

The facility failed to provide adequate supervision for a resident with a history of wandering behaviors in the Special Care Unit. Specifically, the facility allowed the resident access to an unlocked and disarmed outside exit door, which resulted in the resident eloping from the facility.

The facility failed to ensure medications were administered within one hour before or one hour after the scheduled times as ordered. Specifically, for 2 of 2 sampled residents, medications such as aspirin, metoprolol XL, and simvastatin were administered outside of the prescribed 8:00am window.

The facility failed to ensure medications were administered to residents within one hour before or one hour after the prescribed or scheduled time. Specifically, for two sampled residents, medications were documented as administered outside of the required one-hour window. This included instances where 8:00am medications were administered as late as 10:12am.