A True Vision Family Care

The facility failed to ensure that 3 out of 3 sampled residents had completed required two-step tuberculosis (TB) testing. Specifically, medical records for Resident #1 and Resident #2 did not contain available documentation of TB testing.

The facility failed to notify the primary care provider for a resident regarding necessary medical equipment and failed to ensure medication availability. Specifically, an albuterol sulfate medication and a transdermal pain patch were unavailable for administration, and the resident lacked a required nebulizer machine despite physician orders. Additionally, medication packaging was improperly labeled and lacked necessary administration documentation.

The facility failed to ensure proper referral and follow-up for a resident's health care needs. Specifically, the facility did not notify the primary care provider regarding missing inhalation medication and a transdermal pain patch, and there was a lack of documentation for the administration of ordered albuterol sulfate.

The facility failed to ensure consistent medication administration oversight and auditing. The Administrator and Supervisor-in-charge must implement a process to audit medications daily and ensure the medication lock is properly in place.

The facility failed to ensure that 2 of 2 sampled staff members who administered medications had completed the required 5-hour, 10-hour, or 15-hour medication training course and passed the written medication aide examination. Specifically, for Staff A, there was no documentation of completed training or a passed written exam, despite the staff member performing medication administration tasks such as eye drops and inhalers.

The facility failed to ensure that a staff member administering medications had completed the required 5-hour and 10-hour or 15-hour medication training course and passed the state medication aide examination. During an observation, the staff member was found administering eye drops and insulin without proper training documentation or use of gloves.

The facility failed to maintain plumbing in a safe and operating condition. Specifically, the sink in the master bathroom was missing a knob to turn on the hot water, preventing a resident from accessing hot water for hand washing.