The Shaire Center

The facility failed to clarify medication orders for two residents, specifically regarding instructions for a multi-vitamin, an inhaler, and insulin. Discrepancies were found between physician orders, computer-generated entries, and handwritten notes, including contradictory dosing instructions for Novolog.

The facility failed to clarify medication orders for 2 of 5 sampled residents. Specifically, orders for a multi-vitamin and an inhaler change were not clarified, and there were incomplete or conflicting orders for insulin and antifungal cream.

The facility failed to maintain a matching therapeutic diet menu for residents with physician-ordered diets. Specifically, for two sampled residents requiring a pureed diet, no therapeutic diet menu was available in the kitchen to guide food service staff.

The facility failed to maintain a matching therapeutic diet menu for physician-ordered pureed diets. Specifically, for two sampled residents, there was no available menu to guide food service staff in preparing the required pureed consistency.

The facility failed to provide residents in the Special Care Unit (SCU) with a non-disposable place setting that includes a knife, fork, and spoon. Staff were observed serving meals without knives and admitted to withholding them for safety reasons without individual physician assessments or documented exceptions.

The facility failed to ensure the accuracy of Medication Administration Records (MARs) for three residents regarding the documentation of Oxycodone, Tramadol, Guaifenesin cough syrup, and Xanax/Ativan. Specifically, there were significant discrepancies between the Controlled Drug Sheet and the MAR, including failure to document the reason and effect of PRN medications and failure to record administration on the MAR despite entries on the drug sheet.

The facility failed to ensure the accuracy of Medication Administration Records (MARs) for three sampled residents regarding the documentation of medications including Oxycodone, Tramadol, and Xanax. Specifically, discrepancies were found between the Controlled Drug Sheet and the MAR, where numerous doses of Xanax were documented on the drug sheet but not recorded as administered on the MAR.