Toney Rest Home

The facility failed to ensure medications were administered as ordered, resulting in an 11% medication error rate. Specifically, a resident was administered omeprazole at 10:07am despite an order requiring administration a half hour before the 8:00am breakfast.

The facility failed to ensure medications were administered as ordered for one resident. Specifically, a medication for acid reflux was administered at 10:07am instead of the required time of a half-hour before the 8:00am breakfast, and insulin was not administered as scheduled because the medication aide did not wait for the resident to be available.

The facility failed to maintain a clean and hazard-free environment due to multiple unsecured oxygen tanks left on the floor in a resident's room. Additionally, a locked storage room containing oxygen tanks lacked required signage indicating the presence of oxygen.

The facility failed to maintain a clean and hazard-free environment due to multiple unsecured oxygen tanks left directly on the floor in a resident's room. Additionally, a storage room containing oxygen tanks lacked required signage indicating the presence of oxygen.

The facility failed to ensure a resident assessment and care plan were updated within 10 days following a significant change in condition. Specifically, for one resident, the facility did not document the required assessment after changes including a hip fracture, the need for staff assistance with transfers, and the placement of an indwelling catheter.

The facility failed to ensure that 2 of 5 sampled residents had completed the required two-step tuberculosis (TB) testing upon admission. Specifically, for Resident #2, there was no documentation of a second TB skin test or proof that the initial test results were properly read.

The facility failed to provide residents with a non-disposable place setting consisting of a knife, fork, spoon, plate, and beverage containers. Observations during breakfast and lunch revealed residents were using plastic utensils and drinking directly from cartons without glasses or bowls. Additionally, the kitchen lacked an adequate supply of non-disposable forks, spoons, knives, and beverage cups.