Homeplace of Burlington

The facility failed to ensure that 3 of 5 sampled residents had completed the required two-step tuberculosis (TB) testing upon admission. Specifically, records for Resident #3 and Resident #4 showed evidence of only a single TB skin test without documentation of the necessary second step.

The facility failed to ensure electronic medication administration records (eMAR) were accurate for a resident regarding finger stick blood sugar (FSBS) documentation. Specifically, the eMAR lacked sufficient space to enter blood sugar results and failed to document 14 out of 21 scheduled FSBS checks. Additionally, there was no documentation of required interventions or physician notifications when blood sugar levels were outside of ordered parameters.

The facility failed to ensure electronic medication administration records (eMAR) were accurate for a resident. Specifically, the facility failed to properly document the value of a resident's finger stick blood sugar (FSBS) in the medication record.

The facility failed to ensure that two of five sampled staff members had completed the required medication clinical skills checklist and passed the state written examination. Additionally, the facility failed to provide documentation that these staff members had completed the required medication aide training course or had verified previous employment as a medication aide.

The facility failed to ensure proper medication administration competency standards were met. This includes requirements for written examinations, clinical skills evaluations by a registered nurse or pharmacist, and proper documentation of the competency validation process.

The facility failed to ensure the implementation of physician orders for one resident related to daily blood pressure checks. Specifically, there was significant missing documentation for blood pressure readings on the medication administration record (MAR) for both February and March 2023.

Medication aides and certified nurse assistants failed to consistently obtain the daily temperatures of residents.

The facility failed to ensure at least one staff person on the premises at all times had completed an accredited CPR and choking management course within the last 24 months. A review of schedules showed 20 out of 21 shifts between 09/02/21 and 09/08/21 were not covered by CPR certified staff. Specifically, three sampled staff members lacked documentation of current certification.