St. Andrews Living Center

The facility failed to ensure physician's orders were implemented correctly for a resident. Specifically, the resident was administered 5mg of apixaban twice daily despite a new order for 2.5mg twice daily. This error occurred because the pharmacy overlooked the updated dosage during the readmission process, and the facility lacked a second-person review system to verify eMAR accuracy.

The facility failed to ensure physician's orders were implemented for a resident regarding medication to prevent blood clots. Specifically, an order for apixaban 2.5mg twice daily was overlooked, resulting in the resident continuing to receive the previous 5mg dose.

The facility failed to ensure that a criminal background check was completed prior to hire for 3 out of 7 sampled staff members. Specifically, personnel records for certain employees showed that background check documentation was either missing or completed after the hire date.

The facility failed to ensure that a criminal background check was completed prior to hire for 3 out of 7 sampled staff members. Specifically, documentation for some staff showed background checks were completed significantly after their hire dates.