Terrace Ridge Assisted Living

The facility failed to ensure physician's orders were implemented for 2 of 5 sampled residents. Specifically, the facility continued to administer memantine ER to Resident #1 despite an order from a Mental Health Provider to discontinue the medication.

The facility failed to ensure physician's orders were implemented for 2 of 5 sampled residents regarding the discontinuation of medications. Specifically, Resident #1 continued to receive memantine ER despite a provider order to discontinue the medication to treat memory loss.

The facility failed to ensure that exit doors accessible to residents known to be disoriented or wanderers were equipped with audible sounding devices. Specifically, the front entrance and kitchen back exit doors did not trigger an alarm when opened, posing a risk to residents with wandering behaviors.

The facility failed to ensure that two of eight exit doors accessible to residents known to be disoriented or wanderers were equipped with audible sounding devices. This lack of alarms contributed to incidents where residents, including Resident #3, were able to exit the facility unnoticed, leading to an elopement event.

The facility failed to maintain an accurate and current list of residents requiring physician-ordered therapeutic diets. Specifically, two out of three sampled residents were not correctly identified on the kitchen's therapeutic diet list, including a resident requiring a mechanical soft diet with ground meat and a resident requiring a complex renal/diabetic diet.

The facility failed to maintain an accurate and current list of residents requiring physician-ordered therapeutic diets. Specifically, two out of three sampled residents were not correctly identified on the kitchen's therapeutic diet list, including a resident requiring a mechanical soft diet and another requiring a highly specific renal/diabetic diet.