Hummingbird Gardens

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk to the health and safety of residents if the caregiver was not adequately trained, and the Department was provided false and misleading information. Findings include: 1. A review of E4's personnel record revealed E4 was hired as a caregiver. E4's personnel record revealed a Platinum Training Services, ALTP 0185, with a certificate received date of June 25, 2012. 2. A review of Department documentation revealed Platinum Training services, ALTP 0185 was in business from July 16, 2012, through August 2, 20213. 3. In an interview. E1 reported E4 worked at the facility as a caregiver. E1 reported E1 was unaware E4's caregiver certificate was fraudulent. E1 acknowledged the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board).

Based on record review, observation, and interview, the manager failed to ensure medication was administered in compliance with a medication order. Findings include: 1. Review of R2's medical record revealed R2 received medication administration. 2. Review of R1's medical record revealed signed medication orders for Amlodipine Besylate 10 mg tablet take one tablet by mouth daily for Hypertension, Hold for blood pressure less than 110/60." A review of R2's medical record revealed on June 2, 2023 R1's blood pressure read "102/68" and on June 4, 2023 read ""83/64." R2's medication administration record revealed R2 was administered Amlodipine Besylate 10 mg. 3. In an interview. E1 reported E1 believed R2's blood pressure was read multiple times a day and the documented reading reflects R2's blood pressure after receiving the identified medication. E1 reported no additional documentation was available for review to reveal what R2's blood pressure reading was prior to the documented reading. E1 acknowledged R2's medical record only revealed the identified blood pressure reading for the dates identified. E1 acknowledged the blood pressure reading identified in R2's medical record identified a blood pressure reading that would require R2's Amlodipine Besylate 10 mg to be held for that day. E1 acknowledged the manager failed to ensure medication was administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the facility tour with E1, the compliance officer observed one unlocked box in the refrigerator containing the following medications: Lorazepam, Atropine, and Morphine Sulfate. This box had a key locking device; however, was not locked. 2. In an interview, E1 reported the facility had accessed the identified medication box the night prior. E1 acknowledged the manager failed to ensure medications stored by the facility were stored in a locked area.