Bethany Tender Love and Care

The facility failed to ensure the medication administration record (MAR) was accurate for one resident. Specifically, the MAR lacked entries for the administration of trazadone between 10/01/24 and 10/09/24, despite the medication being available for use.

The facility failed to ensure the medication administration record (MAR) was accurate for one resident regarding an antidepressant medication. Specifically, the trazadone 50mg entry was missing from the October 2024 MAR despite the medication still being active and administered by the Administrator. The Administrator failed to identify the missing entry during monthly reviews of the MARs.

The facility failed to ensure that medication was administered according to the prescribed instructions. Specifically, a resident was found to have received medication at an incorrect time or in an incorrect manner, indicating a failure in the medication administration process.

Staff failed to properly document the administration of medications for a resident. This lack of documentation prevents verification that the resident is receiving the necessary prescribed treatments as required by regulation.

The facility failed to maintain accurate medication records. Discrepancies were noted between the medication administration record (MAR) and the actual medication being provided to the resident.

There was evidence that medication was not administered as prescribed. The facility failed to follow the specific timing and dosage instructions outlined in the resident's physician orders.

The facility failed to ensure that all medications were properly labeled and stored. This oversight increases the risk of medication errors and improper dosing for residents.

Staff failed to monitor the resident for adverse effects following the administration of new medications. The facility did not adequately assess the resident's response to medication changes as required.

The facility failed to maintain a system to ensure that all medication orders are reviewed and implemented promptly. Delays in updating medication records were observed during the inspection.

The facility failed to ensure that medication was administered by qualified personnel. There were instances where staff members lacked the necessary training or authorization to perform medication administration tasks.

The facility failed to properly manage controlled substances. Discrepancies were noted in the tracking and documentation of controlled medication usage.

The facility failed to ensure that medication was administered in a way that promotes resident safety. Inadequate oversight of the medication process was observed, potentially leading to errors.

The facility failed to ensure that a criminal background check was completed for one staff member upon hire. A review of the personnel record for Staff A showed no documentation of a background check despite the employee being hired in September 2022.

The facility failed to ensure that one sampled staff member had an examination and screening for the presence of controlled substances completed upon hire. The personnel record for Staff A contained no results for the required screening examination.

The facility failed to ensure tuberculosis testing was completed upon admission for 2 of 3 sampled residents. For one resident, documentation of the TB skin test results and the person administering the test was missing or incomplete, and for another resident, there was no documentation of any TB skin tests.

The facility failed to ensure the physician was contacted for clarification of insufficient or unclear information on the FL-2 form for 1 of 3 sampled residents. Specifically, the resident's FL-2 lacked a diet order and contained an incomplete insulin order without a specified route or frequency.

The facility failed to ensure that tuberculosis testing was completed upon admission for 2 of 3 sampled residents. For one resident, documentation was incomplete regarding test results and the person administering the test, while for another resident, there was no documentation of any tuberculosis skin tests at all.

The facility failed to ensure that 2 of 3 sampled residents were tested for tuberculosis upon admission. Specifically, one resident had clinical data indicating active TB from a chest x-ray without further documentation of testing, and another resident's records lacked required admission testing documentation.

The facility failed to ensure that 2 of 3 sampled residents were tested for tuberculosis upon admission. Specifically, records for Resident #2 showed a chest x-ray indicating active TB with no further documentation of testing, and Resident #3 lacked required admission testing documentation.