Serenity Falls Family Care Home at Durant Trace

The facility failed to document required weekly blood pressure readings for one resident in their electronic medication administration record (eMAR). Although physician orders required weekly checks and staff initials were present on the eMAR, the actual blood pressure values were not recorded for multiple dates in July, August, and September 2024.

The facility failed to ensure that one of three sampled residents had weekly blood pressure readings documented on their electronic medication administration record (eMAR). Although staff initials were present on the eMAR for several weeks in July, August, and September 2024, the actual blood pressure values were not recorded. The Supervisor-in-Charge admitted that readings were not documented because they believed recording was only necessary if the values were outside of specified parameters.

The facility failed to ensure that 2 of 3 sampled residents had an assessment and care plan updated annually. Specifically, for Resident #1, the person completing the assessment did not sign or date the care plan, and for Resident #2, the assessment date listed was outdated.

The facility failed to maintain an accurate Medication Administration Record (MAR) that includes all required elements such as the resident's name, medication name, strength, and dosage.

The facility failed to ensure that 2 of 3 sampled residents had an assessment and care plan updated annually. Specifically, for Resident #1 and Resident #2, the care plans were not updated within the required annual timeframe.

The facility failed to clarify physician orders regarding dietary needs for two residents. Specifically, the administrator or supervisor-in-charge did not seek clarification for a dysphagia II diet and the required consistency of thickened liquids, resulting in residents being served regular diets instead of prescribed therapeutic diets.

The facility failed to ensure that one of three sampled staff members was tested for tuberculosis disease upon employment. Specifically, there was no record of the TB skin test result being read or any documentation of subsequent testing in the employee's record.

The facility failed to ensure that two of three sampled staff members had completed criminal background checks in accordance with state requirements. The review of employee records indicated missing documentation for Staff A and Staff B.

The facility failed to ensure that two of three sampled staff members had completed a statewide criminal history background check. Records showed only a local county check for one staff member and no documentation of a criminal history background check for the second staff member.

The facility failed to ensure that one of three sampled staff members was tested for tuberculosis disease upon employment. There was no documentation on file to prove the staff member was free of tuberculosis disease as required by control measures.