El Bethel Family Care Home

The facility failed to notify the Division of Health Service Regulation that the evacuation capabilities of two sampled residents had changed from the capabilities listed on the facility's license. This was identified during a fire drill where two residents did not exit the facility. Additionally, fire drill logs were incomplete, lacking documentation for the number of residents participating, whether they reached the assigned spot, and if the fire alarm was operational.

The facility failed to comply with regulations regarding its licensed capacity. Specifically, the facility must ensure the total number of residents does not exceed the number shown on the license and must maintain appropriate capacity for both ambulatory and non-ambulatory individuals.

The facility failed to ensure medications were administered as ordered for 2 of 2 sampled residents regarding blood sugar management. Specifically, for Resident #1, there was no documentation that finger stick blood sugar (FSBS) was checked before lunch or dinner during November 2024 and December 2024, despite physician orders for Humalog insulin to be administered via a sliding scale before meals.

The facility failed to ensure medications were administered as ordered for 2 of 2 sampled residents regarding blood sugar management. Specifically, Resident #1's blood sugar was not checked before lunch or dinner as required by the physician's sliding scale insulin orders, and the resident was self-administering a fixed dose of insulin regardless of glucose levels.

The facility failed to ensure a functional assessment and care plan were completed within 30 days of admission for three sampled residents. Specifically, for Resident #1, no care plan was available for review despite an admission date of 12/20/22.

The facility failed to ensure a functional resident assessment/care plan was completed within 30 days of admission for three sampled residents. Specifically, for residents admitted in December 2022, January 2023, and February 2023, no care plans were available for review.

The facility failed to complete an initial resident assessment using the Resident Register within 72 hours of admission for one resident. A review of the resident's record showed no Resident Register was available, despite medication administration having begun on the date of admission.

The facility failed to ensure that the preparation and administration of medications and treatments by staff were in accordance with orders by a licensed prescribing practitioner and facility policies.

The Administrator failed to check MARs received from the pharmacy every 30 days or when a new MAR was requested due to significant medication changes.

The Administrator failed to properly check medications received from the pharmacy against the MARs to ensure accuracy. Additionally, there was a failure to ensure all medications were received and available for resident administration.

The Administrator failed to review staff records to ensure that all staff administering medication had completed the required training, clinical skills validation, and passed the written examination within 60 days of beginning duties.

The Administrator failed to ensure that the Resident Register was completed within the first three days of admission for new residents.