Above and Beyond Family Care

The facility failed to ensure that a controlled substance examination and screening was completed for a staff member prior to their hire date. A review of a medication aide's personnel record showed no documentation of the required screening was available before they began working.

The facility failed to ensure proper contact with a physician or prescribing practitioner for the verification or clarification of medication orders, treatments, or admission orders.

The facility failed to ensure that a controlled substance screening was completed and documented in the personnel file for one of three sampled staff members prior to hire. While the staff member reported the screening was performed, the results were missing from the official personnel record.

The facility failed to ensure that one of three sampled staff members who administered medications had completed the required state-approved medication aide training courses and clinical skills validation. Personnel records lacked documentation for the staff member's written exam results, competency validation checklist, and employment verification form.

The facility failed to notify the Division of Health Service Regulation that the evacuation capabilities of residents had changed. Specifically, for 2 out of 4 sampled residents, the evacuation capabilities differed from those listed on the facility's license.

The facility failed to ensure that the Owner and/or Administrator notifies DHSR of changes in a resident's condition that would require verbal prompting or physical assistance. Additionally, the facility failed to make appropriate discharge plans for residents experiencing such changes in condition.

The facility failed to ensure staff immediately documented the administration of medications for 2 of 3 sampled residents. Specifically, the Medication Aide failed to record the administration of several medications, including amlodipine, citalopram, and melatonin, on the medication administration record (MAR) at the required time.

The facility failed to ensure evacuation capabilities were in accordance with the facility's current license for 3 non-ambulatory residents. Specifically, the facility was licensed for 5 ambulatory residents, but Resident #2 had become non-ambulatory following a hospital discharge, requiring assistance with transfers and activities of daily living.