Oakbridge Terrace at Granite Farms Estates.

“Three staff members (Staff Person A, B, and C) administered prescription medications to residents without being medical professionals or having completed the Department's medication administration training.”

“A medication was found in the residence's Director of Assisted Living Office but was not ordered for the resident it was prescribed for.”

“Two residents who permanently left the residence did not receive their medications (Pregabalin and another medication) upon discharge, as required by regulation.”

“Staff Person D took possession of a resident's controlled substance directly from the resident without a delivery manifest, violating the residence's medication policy requiring controlled substances be delivered from a pharmacy with a manifest.”

“The facility's current license dated 5/7/23 was not posted in a conspicuous and public place in the residence.”

“Bedside mobility devices with openings measuring 8 inches wide by 11 inches long were attached to Resident 1's bed but the device openings were not covered, posing a possible hazardous condition for the resident.”

“Hot water temperatures in resident rooms exceeded the maximum allowable temperature of 120°F, measuring 133.5°F, 126.5°F, and 138°F in three separate rooms.”

“A resident did not have access to a source of light that can be turned on/off at bedside.”

“Medication containers for two residents had changed directions that were not indicated on the medication labels. One resident's Calcium Carbonate direction was changed from "take 1 tablet by mouth every night" to "give 1 tablet by mouth in the afternoon for supplement," and another resident's medication direction was changed from "take 1 tablet by mouth once a day" to "give 1 tablet by mouth in the afternoon for hypertension hold for Heart Rate less than 60 or Systolic Blood Pressure less than 110" without the changes being reflected on the container labels.”

“Multiple medication administration and monitoring deficiencies were identified: blood glucose readings were not documented on Medication Administration Records, one reading was documented incorrectly, and a glucometer was not calibrated to the correct time.”

“Two instances of failure to follow prescriber's orders were identified: a resident prescribed to have glucose checks four times daily did not have a reading registered on the glucometer at one scheduled time, and a resident prescribed medication twice daily for arthritis was not administered the medication at bedtime on 2/11/24.”