Sayre Personal Care Residence

A staff member was observed yelling at a resident during a verbal altercation in the dining room.

Staff incorrectly transcribed blood glucose test results from the glucometer into the Medication Administration Record (MAR).

A resident was out of the facility and did not receive prescribed medications as directed by the prescriber.

A resident did not receive required assistance with personal hygiene and ambulating for 4 hours and was left unattended.

A resident was not treated with dignity and respect after staff removed soiled bed sheets but failed to replace them.

Bed linens were not replaced with clean sheets following an accident, leaving the resident to sleep on a plastic mattress cover.

A resident's medical evaluation documentation was incomplete as the medication section lacked the required attached documentation.

Medications were found unlocked, unattended, and accessible in a resident's room.

A resident's glucometer was not calibrated to the correct time of day, and blood glucose readings were incorrectly documented on the Medication Administration Record.

A resident's medication administration record contained incorrect dosing instructions for a PRN medication compared to the pharmacy label.

Staff administered incorrect units of insulin and failed to follow physician orders regarding medication administration during low blood glucose readings.

A resident required physical assistance with incontinence briefs but was found with briefs soaked through with urine due to lack of changes.

A resident was not treated with dignity when staff failed to change briefs, left dentures under the resident, and a staff member yanked on the resident's arm during a transfer.

Staff failed to report an allegation of verbal abuse to the Department's hotline within the required 24-hour period.

A staff member failed to treat residents with dignity and respect by using insulting language and derogatory comments.

Resident privacy coding was attached to a public inspection binder, and a computer with visible resident information was left unattended on a medication cart.

Contracts for two residents were found to be missing the required resident signatures.

Two direct care staff members had not completed or passed the Department-approved direct care training course and competency test.