Brockett House 2

The facility failed to ensure that an appropriate licensed health professional participates in the on-site review and evaluation of residents' health status and care plans. This is required for residents needing specific personal care tasks such as wound care, catheter management, or medication administration via feeding tubes.

The facility failed to ensure a Licensed Health Professional Support (LHPS) evaluation was completed for a resident requiring fingerstick blood sugar (FSBS) checks. While the resident required daily FSBS monitoring, no LHPS evaluations had been performed since February 2023.

The facility failed to ensure medication administration records were accurate for a resident. Specifically, there was inaccurate documentation regarding a medication prescribed for the prevention of blood clots.

The facility failed to develop an updated annual care plan for one of three sampled residents. Specifically, the Administrator had not completed a required annual care plan for Resident #3 since September 2018.

The facility failed to ensure the provision of pharmaceutical care by a licensed pharmacist, prescribing practitioner, or registered nurse at least quarterly for residents.

The facility failed to develop an updated care plan for one of three sampled residents (Resident #3) following their annual review. The last care plan on file for this resident was dated 09/25/18, and the administrator acknowledged that the plan was due for completion in September 2019.

The facility failed to ensure that pharmaceutical reviews were completed at least quarterly for three of three sampled residents. Specifically, for Resident #1, the review process was not consistently maintained to ensure medication administration records were current with medication orders.

The facility failed to ensure that controlled substance examination and screening was performed for one of three staff members hired after 10/01/2013. A review of the personnel file for a Supervisor-in-Charge/Medication Aide revealed no documentation of the required screening completion.

The facility failed to ensure that a controlled substance examination and screening was performed and documented for a staff member hired in April 2016. The Administrator could not locate the results in the personnel file and had placed them in an unidentifiable folder. Subsequent review showed the screening was not completed until November 2016, months after the employee's hire date.