A Touch of Excelence, LLC

Based on record review, documentation review, and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2’s current service plan, dated September 26, 2025, revealed R2 received medication administration. 2. Review of R2’s medical records revealed a Patient Discharge form from Banner Boswell Medical Center dated January 18, 2026. The Discharge form revealed a signed change to R2’s medication order: “Take Pantoprazole twice a day.” 3. Review of R2’s medical records revealed a Medication Administration Record (MAR) dated January 2026 and February 2026. The January MAR revealed: “Pantoprazole 40mg Delay release 1 tab PO QD: 8 AM, January 18-31.” The February MAR revealed: “Pantoprazole 40mg Take 1 tablet PO BID: 8 AM, February 1-9” 4. A review of the facility’s policies and procedures revealed a policy titled, “Medications” which stated the following: a. “31) There have been many safeguards established to ensure the rights are followed in regards to medication administration: c) Prior to administration of medication verification steps are taken to verify correct dosage is used. i) Medication doses are checked by using the ration and proportion, basic formula fractional equation. ii) Recommended dosage range for the drug is checked. b. f) Update MAR as soon as possible.” 5. In an interview with E2, E2 reported the medications were administered one time per day as documented in the MAR. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a medication administered to a resident is documented in the resident’s medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s current service plan, dated December 2, 2025, revealed R1 received medication administration. 2. Review of R1’s medical records revealed a signed Resident Medication List dated January 21, 2025. The medication list included “Midodrine 2.5mg 1 tab BID PRN if SBP <110.” 3. Review of R1’s medical records revealed a Resident Vital Sign Record sheet dated December 2025 and January 2026. The Vital Sign record revealed R1’s systolic blood pressure (SBP) fell below 110 on the following dates: a. December 21: BP 105/63 b. January 28: BP 108/75 c. January 30: 108/69 4. Review of R1’s medical records revealed a PRN Medication Administration Record (MAR) dated December 2025 and January 2026. The MAR revealed “Midodrine 2.5 mg 1 tab BID PRN if SBP <110.” The MAR revealed the following medication administrations were not documented, in accordance with R1’s vital signs above: a. December 21, 2025 b. January 28, 2026 c. January 30, 2026 5. A review of the facility’s policies and procedures revealed a policy titled, “Medications” which stated, “11. The trained caregiver will sign off the medication for the date and time the medicine was given to the resident and the medications taken by initialing the Medication Administration Record (MAR) or completing the PRN flow sheet.” 6. In an interview with E2, E2 reported that medications were administered but were not documented in the MAR. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to cover in-service education, for four of six employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance, and the documentation was not provided within two hours after a Department request. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of the facility's policies and procedures revealed a policy titled "On-going Training Guidance" (dated February 2022). The policy stated "All employees will complete at least 12 hours of ongoing training every 12 months from the date of hire based on level of care provided to the facility, and to cover current residence needs for care." 2. A review of E2's personnel record revealed E2 was hired as caregiver in April 2021. However, the personnel record revealed E2 completed two hours of in-service education within the past 12 months. 3. A review of E3's personnel record revealed E3 was hired as a caregiver in April 2021. However, the personnel record revealed E3 completed two hours of in-service education within the past 12 months. 4. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in April 2022). However, the personnel record revealed E4 completed two hours of in-service education within the past 12 months. 5. A review of E5's personnel record revealed E5 was hired as an assistant caregiver in March 2022. However, the personnel record revealed E5 completed two hours of in-service education within the past 12 months. 6. In an interview, E1 acknowledged E2's, E3's, E4's, and E5's personnel records did not include documentation of completion of 12 hours of in-service education every 12 months from date of hire, as required by the facility's policies and procedures.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of E2's personnel record revealed E2 was hired as caregiver in April 2021. The personnel record revealed E2 completed two hours of in-service education within the past 12 months. However, 12 hours of ongoing training every 12 months from the date of hire was not available for review. 2. A review of E3's personnel record revealed E3 was hired as a caregiver in April 2021. The personnel record revealed E3 completed two hours of in-service education within the past 12 months. However, 12 hours of ongoing training every 12 months from the date of hire was not available for review. 3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in April 2022). The personnel record revealed E4 completed two hours of in-service education within the past 12 months. However, 12 hours of ongoing training every 12 months from the date of hire was not available for review. 4. A review of E5's personnel record revealed E5 was hired as an assistant caregiver in March 2022. The personnel record revealed E5 completed two hours of in-service education within the past 12 months. However, 12 hours of ongoing training every 12 months from the date of hire was not available for review. 5. In an interview, E1 acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request.