Print Inspection: TEEO

Based on interview and record review, conducted during a site visit on 05/19/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of Resident 4's August 2024 Medication Administration Record (MAR) indicated the following order: Humilin 100 unit/ml, 20 units subcutaneously, one time a day for Type 2 Diabetes Mellitus.

Resident 1's physician orders, dated 08/08/24, indicated s/he was to receive Humalin 100 units/ml every morning before breakfast.

An incident report, dated 08/08/24, indicated Resident 4's new insulin order had been entered into the Electronic Medical Record incorrectly and was subsequently administered 20 units of Humalog instead of the ordered Humilin.

In an interview, Staff 2 (Campus Director) stated s/he recalled the incident.

The findings were reviewed with and acknowledged by Staff 1 (Administrator).

The facility's failure to carry out medication orders as prescribed was substantiated.

Based on interview and record review, conducted during a site visit on 05/19/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sample resident (# 3). Findings include, but are not limited to:

An incident report, dated 09/16/23, indicated Resident 3 had been administered another resident's medication.

A review of Resident 3's progress notes, dated 09/16/23 to 09/22/23 indicated s/he received the following medications in error:

* Atorvastatin, 40 mg;

* Carbidopa Levodopa 25-100;

* Tramadol 50 mg; and

* Trazodone 50 mg.

A review of Resident 3's signed physician orders, dated 08/01/23, did not indicate s/he had active orders for the ingested medications and/or doses.

In an interview, Staff 1 (Administrator) stated s/he remembered the incident.

The findings were reviewed with and acknowledged by Staff 1.

The facility's failure to carry out medication orders as prescribed was substantiated.

Based on interview and record review, conducted during an investigation on 07/14/25, the facility's failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to:

A review of electronic communication, dated 07/14/25 through 07/28/25, indicated the Department requested documents related to resident medical records. The facility had not provided all requested documentation by the due date of 07/16/25.

The facility's failure to provide records to the Department upon request was substantiated.

The findings were reviewed with Staff 1 (Administrator) and Staff 2 (Campus Director) via electronic communication on 07/28/25.