Angel House V

The facility failed to ensure that one of three sampled medication aides had successfully passed the state medication aide exam within 60 days of completing training. Personnel records for Staff B showed completion of training and competency checklists, but lacked documentation of the required state exam. Consequently, the staff member was performing unsupervised medication administration without meeting all regulatory requirements.

The facility failed to ensure physician notification for a resident who had a specific order to notify the Primary Care Provider for blood pressure readings outside of set parameters. Specifically, the facility did not notify the provider despite multiple documented blood pressure readings exceeding the ordered systolic or diastolic limits.

The facility failed to follow proper blood pressure parameters within the Quick MAR system. There was a lack of adequate health care follow-up regarding medication orders and resident charts.

The facility failed to adequately monitor health care orders, impacting the oversight of resident care requirements.

The facility failed to ensure the wooden landing at the side entrance was free of obstructions and impediments. Specifically, the wooden floor slats were badly deteriorated with large holes exposing the ground and supporting beams. Additionally, a metal chair was propped against a railing near the damaged area.

The facility failed to ensure that therapeutic diets, including low fat and low sodium requirements, were served as ordered by the physician. Specifically, food items used to prepare Resident #3's meal, such as turkey, swiss cheese, and mayonnaise, did not meet the low sodium or low fat specifications required by the resident's diet order.

The facility failed to ensure follow-up for a resident's health care needs. Specifically, lab work ordered by a physician for Resident #2 was not obtained, and staff were unaware that the labs had been ordered.

The facility failed to ensure that the preparation and administration of medications and treatments by staff were in accordance with physician orders.