Print Inspection: 9HF0

Based on interview and record review, conducted during a site visit on 06/25/24, it was confirmed the facility failed ensure a safe medication administration system for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

A review of Resident 2's January 2024 MAR and progress notes indicated the following:

·There were nine occurrences where a medication was not given due to the facility not having it available.

In separate interviews, Staff 1 (Executive Director) and Staff 3 (MT) stated the following:

·The med cards had numbers on them and when it got to the blue section, they re-ordered.

·Occasionally they ran out of a medication.

·Sometimes they were waiting on the doctor.

·There was a new policy with med cart audits on a weekly basis.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/25/24.

It was confirmed the facility failed to ensure a safe medication administration system.

Verbal plan of correction: Management went over the medication re-ordering process in the monthly all staff meeting after the incident and in the med tech training meeting. RCC's are now doing a weekly audit of medications including liquid, spray, and oral medications.

Based on interview and record review, conducted during a site visit on 06/25/24, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 2 of 2 sampled staff (#s 4 and 5). Findings include but are not limited to:

A review of completed training documents for Staff 4 (MT) and Staff 5 (CG) indicated the following:

·Staff 4 was hired on 02/20/24 and did not have completed competency/skill checklists for CG or MT duties.

·Staff 5 was hired on 04/19/24 and did not have completed competency/skill checklists for CG duties.

During an interview on 06/25/24, Staff 1 (Executive Director) stated they were unable to locate some of the completed training documents for some staff.

The findings were reviewed with and acknowledged by Staff 1 on 06/25/24.

It was determined the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing.

Plan of correction: ED and RN will immediately do an audit of all staff training records to make sure staff have documented training in the file. All staff will be retrained, and paperwork will be filled out as needed. ED will also find a new space to keep records to prevent loss of paperwork in the future.