Fellowship Terrace.

“A spray bottle of blue liquid was found in the medical supply closet in the Villa without a manufacturer's label, violating requirements that poisonous materials be stored in their original, labeled containers.”

“Menus posted in the Secured Dementia Care Unit were dated December 2024 and were not current, failing to meet requirements that weekly menus be posted one week in advance.”

“A clipboard containing resident names, room numbers, and weights was left unattended at the bottom of a ramp in the Villa area without staff supervision, violating confidentiality requirements.”

“Three landline phones located in the Terrace, Villa East Hall, and Courtyard kitchens did not have emergency telephone numbers posted on or near them, as required.”

“Resident #1's RASP assessment did not include documentation of the enabler bar use, including the specific need, intended use, associated risks, ability to use safely, device identification, or FDA coverage requirements.”

“The home failed to report injuries to the head suffered by a resident as a result of care provided by a private duty aide within the required 24-hour timeframe. The report was submitted approximately 30 minutes late.”

“A resident suffered injuries to the head as a result of care provided by a private duty aide between 11pm and 6:45am. The private duty aide did not report the injuries or have the resident assessed for medical treatment, constituting neglect.”

“Staff member A administered medication to the wrong resident at approximately 7pm on 5/8/24 by entering the incorrect resident's room. The error violated the requirement to identify the correct resident before medication administration.”

“A resident frequently refused prescribed medications during April 2024, including refusals from 4/9/24-4/24/24, 4/8/24-4/12/24, and 4/8/24-4/19/24. The home did not document that the prescribers were notified of these medication refusals as required within 24 hours.”

“Poisonous materials including Purell hand sanitizer, Skin Repair Cream labeled with poison control instructions, and Nail Polish Remover pads were found in an unlocked and unattended cabinet in the Courtyard Activity Area. Residents in this dementia care unit are not assessed to safely identify or use poisonous materials.”

“Two trays of yellow cake on dessert plates were stored in the refrigerator uncovered and not labeled or dated. A jug of maple syrup was found on the counter half empty with no date indicating when the bottle was opened.”

“Two plastic deli bags of turkey breast labeled 'Discard 3/13/24' and one block of sliced cheese labeled 'Discard 3/12/24' were found in the main floor kitchen area refrigerator.”