Shuler Health Care/record Villa

The facility failed to ensure that 2 of 3 sampled residents had completed the required two-step tuberculosis (TB) testing. Specifically, one resident's records lacked documentation for the date the TB skin test results were read, and another resident had no documentation of a two-step TB skin test being administered at all.

The facility failed to ensure that 2 of 3 sampled residents had completed the required two-step tuberculosis (TB) testing in compliance with public health control measures.

The facility's RCD or Administrator must consult with family, responsible persons, or guardians to obtain necessary payment or information during delays in medication ordering or delivery to prevent missed doses.

The facility failed to maintain a clean and orderly environment free of hazards due to the presence of live and dead bed bugs in multiple resident bedrooms. Observations included bed bugs on sheets, blood spots on pillowcases, and a lack of mattress protectors or bed bug interceptors on bed legs. Interviews indicated that some rooms had not been treated for bed bugs in six months or more.

The facility failed to prevent residents without self-administration orders from keeping medications, such as topical creams and inhalers, in their personal possession. There were also issues with managing out-of-stock medications and unauthorized medications being present on the MAR.

The facility failed to ensure follow-up appointments were properly tracked and attended, specifically regarding a dermatologist visit. Additionally, blood pressure parameters were not correctly updated or documented in the medication administration system.

The facility failed to adequately monitor and address resident skin concerns related to bedbug bites. There was a lack of consistent medical review for residents presenting with numerous bites.

The facility failed to maintain accurate medication administration records, specifically regarding documentation of medications administered, out-of-stock items, and refusals. Errors were identified in the charting process.

The facility experienced ongoing bedbug issues requiring multiple pest control companies. Staff were not consistently following protocols for prevention, and bedbug covers were occasionally mixed with regular linens.

The facility failed to ensure that all medication bottles were accurately labeled with current orders. Discrepancies were found between the medication bottles and the actual physician orders.

A staff member failed to adhere to the required table setting standards for meal service. The facility failed to ensure all staff were aware of the specific requirements for fork, knife, and spoon placement.

The facility failed to ensure that residents obtaining their own medications, inhalers, or creams had the appropriate self-administration orders on file. Staff failed to remove unauthorized self-held medications from resident possession.

The facility failed to provide matching therapeutic diet menus for physician-ordered diets to guide food service staff. Specifically, for four sampled residents, there were no Cardiac Prudent, Low Concentrated Sweets (LCS), or No Added Salt (NAS) menus available. This lack of guidance resulted in residents being served regular diet menus that did not reflect their specific dietary restrictions.

The facility failed to provide matching therapeutic diet menus for all physician-ordered diets to guide food service staff. Specifically, no Cardiac Prudent menus were available for Residents #2 and #4, and no Low Concentrated Sweets (LCS) or No Added Salt (NAS) menus were available for Residents #1 and #3.