Divine Family Care Home III

The facility failed to ensure physician orders were implemented for a resident regarding the use of compression stockings. Documentation in the medication administration record (MAR) showed no evidence that the ordered stockings were applied or monitored during September and October 2024. Physical observation confirmed the resident was not wearing the required stockings and exhibited swelling.

The facility failed to ensure physician orders for compression stockings were implemented for a resident. Observations showed the resident was not wearing the prescribed stockings, and there was no documentation of the treatment in the medication administration records for September or October 2024.

The facility failed to administer medications in accordance with orders from a licensed prescribing practitioner. Specifically, for one resident, the facility continued to administer paliperidone ER 3 mg daily despite physician orders dated 03/11/21 and 05/28/21 to discontinue that specific dosage.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, the facility continued to administer paliperidone ER 3 mg during May and June 2021 despite a physician's order from March 2021 to discontinue the medication. This error persisted because the medication aide was unaware of the discontinuation order and the pharmacy continued to dispense the medication.

The facility failed to provide a matching therapeutic diet menu for a resident ordered to be on a no concentrated sweets (NCS) diet. While regular and low sodium menus were available, there was no specific NCS menu available to guide food service staff.

The facility failed to ensure that three sampled staff members (Owner, Staff B, and Staff C) had completed a course on CPR and choking management within the past 24 months. Specifically, the Owner's certification had expired in March 2019, Staff B's certification expired in May 2019, and there was no documentation of training for Staff C.

The facility failed to ensure that three sampled staff members had completed required CPR and choking management training within the last 24 months. Specifically, the owner's certification expired in March 2019, and a medication aide's certification expired in May 2019.

The facility failed to report two low blood pressure readings for a resident on antihypertensive medication (Lisinopril) to the Primary Care Provider, despite specific orders to report readings outside of ordered parameters. Specifically, readings of 79/64 on 7/15/17 and 86/65 on 8/15/17 were not communicated to the physician.

The facility failed to report two low monthly blood pressure readings for a resident on antihypertensive medication. Specifically, the facility did not notify the Primary Care Provider when blood pressure readings fell below the ordered parameters of 90/40 in July and August 2017.