Stephenson Family Care Home

The facility failed to ensure that resident FL-2 forms were completed with necessary physician orders. Specifically, for one resident, the FL-2 form lacked orders for Senna and Vitamin D3, even though those medications were being administered according to the physician order sheet and medication administration records.

The facility failed to ensure that Resident #3's FL-2 medical examination forms were completed and up to date. Specifically, the facility failed to provide the resident's updated FL-2 to the contracted pharmacy, leading to discrepancies between physician orders and the medication administration record.

The facility failed to ensure drug screening for the presence of controlled substances was completed and documented in the personnel file for one staff member. While a home-based test was reportedly performed, the results were not maintained in the employee's record.

The facility failed to ensure that one of the sampled residents was not admitted for the treatment of mental illness, alcohol, or drug abuse. Based on observations and reviews, the resident's admission did not meet the required criteria for exceptions.

The facility failed to ensure drug screening for the presence of controlled substances was documented in a staff member's personnel file. While a home-based drug screening was conducted for Staff A, the results were not maintained in the official personnel record.

The facility failed to ensure that a resident was not admitted for the treatment of a mental illness. Resident #3 was admitted to the facility despite having a diagnosis of major depressive disorder and receiving medication for depression.

The facility failed to conduct at least four fire evacuation rehearsals annually and lacked a written fire safety policy. During an observed drill, residents failed to evacuate immediately without verbal prompting from the Administrator.

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The facility failed to conduct the required four annual fire evacuation rehearsals and lacked a formal fire safety policy. During an observed drill, residents failed to evacuate the building independently upon hearing the alarm, and previous drill records lacked necessary details such as evacuation times.

The facility failed to ensure that residents were tested for tuberculosis disease upon admission in compliance with required control measures. The rule requires testing for each resident as specified by the Commission for Health Services.

The facility failed to ensure one of two sampled staff members was properly tested for tuberculosis upon hire. Specifically, there was no documentation that a required second tuberculosis skin test was administered and read for the employee.

The facility failed to ensure that one of three sampled residents was tested for tuberculosis disease upon admission to the family care home.