Shuler Health Care/phillips Villa

The facility failed to ensure medications were administered according to physician orders for one resident. Specifically, the facility continued to administer mirtazapine to Resident #3 despite orders to discontinue the medication in July and August 2024. The discontinuation orders were not updated on the electronic medication administration record (eMAR) or communicated to the pharmacy.

The facility failed to ensure medications were administered according to physician orders. Specifically, for one resident, an order to discontinue the medication mirtazapine was not updated on the electronic medication administration record (eMAR), resulting in the medication being administered for several weeks after the discontinuation order was issued.

The facility failed to ensure medications were administered in accordance with orders by a licensed prescribing practitioner. Specifically, for one sampled resident, a medication used to treat muscle spasticity was not administered as ordered by the physician.

The facility failed to ensure physician orders were implemented for a resident with a prescription for tizanidine to treat muscle spasticity. There was no entry in the electronic medication administration record (eMAR) for the medication, and no documentation that it was administered as ordered.

The facility failed to ensure physician orders were implemented for a resident requiring tizanidine for muscle spasticity. Specifically, there was no documentation in the electronic medication administration record (eMAR) showing the medication was administered as ordered from 08/11/21 to 08/18/21.

The facility failed to ensure that all staff were tested for Tuberculosis (TB) disease upon hire. Specifically, one of three sampled staff members was not documented as having received a TB skin test upon being rehired in 2016.

The facility failed to ensure that a criminal background check was completed prior to hire for one of three sampled staff members. Documentation showed no criminal background check was performed when Staff B was rehired on 03/10/16.

The facility failed to ensure that all staff were tested for tuberculosis disease upon employment. Specifically, one staff member's record lacked documentation of a TB skin test upon their rehire in 2016 and lacked a test within the previous 12 months. Additionally, another staff member's record showed a TB skin test with no documented read date.