The Parc at Sharon Amity

The facility failed to ensure referral and follow-up to meet the acute health care needs for Resident #6, who was refusing meals. There was no documentation that the Primary Care Provider was notified of the meal refusals, which prevented the implementation of necessary nutritional interventions like supplemental shakes.

The facility failed to ensure that each resident was served a minimum of three nutritionally adequate meals at regular times. Specifically, Resident #6 was not provided breakfast or lunch trays in the dining room when refusing to leave her bed, and staff failed to provide alternative meal service to meet nutritional requirements.

The facility failed to ensure proper referral and follow-up to meet the acute health care needs of a resident. Specifically, there was no documentation that the Primary Care Provider was notified that Resident #6 was refusing meals, and there was no evidence of communication between care staff regarding this change in condition.

The facility failed to ensure that a resident was served the correct physician-ordered diet. Specifically, a resident prescribed a mechanical soft diet was observed being served a regular consistency meal consisting of turkey, biscuit, sweet potatoes, and zucchini strips.

The facility failed to ensure that a resident was served the correct physician-ordered diet. A review of records showed a discrepancy between the resident's prescribed mechanical soft diet and the diet orders documented in the kitchen, leading to potential inaccuracies in meal service.

The facility failed to ensure a resident was free from physical and mental abuse following a shower refusal, which resulted in a fractured vertebra and a seventeen-day hospitalization. Specifically, there was no documentation of interventions used to manage the resident's aggressive behavior or the refusal of care.

The facility failed to ensure a resident was free from physical and mental abuse during a shower refusal. Two staff members allegedly forcefully threw the resident in the bathtub and into bed, resulting in a lumbar vertebra fracture that required hospitalization and a kyphoplasty procedure.

The facility failed to ensure medications were properly labeled for 2 of 6 sampled residents. Specifically, a pharmacy-generated label on a medication pouch for Resident #4 did not reflect a recent physician's order change for insulin dosage, leading to an incorrect administration attempt.

The facility failed to ensure medications were properly labeled for 2 of 6 sampled residents. Specifically, for Resident #4, the pharmacy-provided pouch for Novolog FlexPen contained an outdated dosage instruction (20 units) that did not reflect a recent physician order change to 23 units.