Tore's Home # 22

The facility failed to administer medications as ordered for one resident regarding a vitamin B12 supplement. While the physician ordered 500mcg daily, the facility was using a 1000mcg supplement provided by a family member. The medication aide failed to identify the incorrect dosage on the label, resulting in the resident receiving double the prescribed dose.

The facility failed to administer medications as ordered for one resident related to a vitamin supplement. While the physician ordered 500mcg of Vitamin B12 daily, the resident was being administered 1000mcg tablets provided by a family member. The medication aide failed to verify the dosage on the label against the physician's orders and the eMAR.

The facility failed to ensure a resident was free from mental abuse and neglect by using disciplinary actions to restrict rights. Specifically, staff removed telephone privileges and utilized a Geri-chair as a form of punishment in response to the resident's behaviors.

The facility failed to ensure a resident was free from mental abuse and neglect. Specifically, staff used the restriction of telephone communication and the use of a geriatric chair as forms of disciplinary action against the resident.

The facility failed to ensure that bed rails were used only after obtaining a written physician order, completing a team assessment and care planning process, and attempting safer alternatives. Specifically, for one resident, bed rails were being used to prevent the resident from getting out of bed without meeting these regulatory requirements.

The facility failed to ensure that bed rails were used only after obtaining a written physician order, conducting a team assessment, and implementing a care planning process. Specifically, Resident #3 had full-length bed rails in use to prevent them from getting out of bed without a physician's order or documented evidence that alternatives were tried first.

The facility failed to provide a complete set of non-disposable flatware, including a knife, fork, and spoon, during meal service. Observations during lunch showed residents were provided only a fork and a napkin, despite the requirement for a full place setting.

The facility failed to provide an activity calendar for all residents and did not ensure a minimum of 14 hours per week of planned group activities. Observations showed no activity calendar was posted and no activities were offered during the survey period.

The facility failed to maintain accurate documentation for the administration of the controlled substance clonazepam for Resident #3. Specifically, the facility could not accurately reconcile the administration of the medication based on the records reviewed.