Terrabella Shelby

The facility failed to ensure medication containers had correct labels for Resident #2. Specifically, furosemide and spironolactone bottles did not match the active physician orders, and the facility failed to use 'change' labels to identify direction changes until new pharmacy labels arrived.

The facility failed to ensure medication containers had correct labels for one resident. Specifically, a bottle of furosemide contained incorrect dosing instructions that did not match the resident's active physician order, and the container lacked the required 'change' medication label.

The facility failed to provide adequate supervision for a resident with a known history of wandering and Alzheimer's disease, resulting in the resident eloping from the Special Care Unit. Staff were unable to account for the resident's whereabouts, and required two-hour safety checks were being performed but not documented.

The facility failed to provide adequate supervision for a resident with a known history of wandering and Alzheimer's disease, resulting in the resident eloping from the Special Care Unit. Staff were unaware of the resident's absence, and required two-hour safety checks were being performed without documentation.

The facility failed to ensure that one of five sampled residents had a care plan completed within 30 days of admission. Specifically, Resident #4 was admitted on 04/21/23, but the care plan was not completed until 06/21/23.

The facility failed to ensure one of five sampled residents had a care plan completed within 30 days of admission. Specifically, Resident #4's care plan was not completed until 60 days after their admission date.

The facility failed to provide adequate supervision for one resident, which resulted in the resident eloping from the locked Special Care Unit. The resident was able to access an enclosed outside courtyard by passing through a sitting room door.

The facility failed to ensure therapeutic diets were served as ordered for three residents. Specifically, the facility did not provide nectar-thickened liquids for residents requiring them and failed to provide a diabetic diet for one resident. Additionally, kitchen menus lacked instructions on how to modify regular diets to accommodate nectar-thickened liquids.

The facility failed to ensure therapeutic diets were served as ordered for three residents. Specifically, Resident #6 was served vegetable medley soup with thin liquid broth instead of the required nectar-thickened consistency, and Resident #5 required a diabetic diet that was not properly managed. The facility had disposed of its thickening powder due to expiration and lacked instructions on how to modify regular diets for nectar-thickened needs.