Evergreen Living Home #13

The facility failed to maintain resident records in an orderly manner that is readily available for review. During the survey, it was observed that no resident records were kept at the facility for 3 of 3 sampled residents.

The facility failed to maintain resident records in the family care home so they were readily available for review. Specifically, medical records for three sampled residents were being kept in the main office rather than within the facility where the residents reside.

The facility failed to ensure that aspirin was administered to Resident #1 as ordered by a licensed prescribing practitioner. A review of medication records showed no documented administrations of the 81mg daily aspirin, and the medication was not available in the resident's personal supply during observation.

The facility failed to ensure that aspirin was administered as ordered to one resident. There was no entry for the prescribed 81mg daily aspirin on the resident's Medication Administration Records (MARs) for October 2016, December 2016, or January 2017. Additionally, the facility failed to notify the prescribing practitioner regarding the resident's refusal of the medication due to stomach upset.