Tower of Blessing a Refuge to Seek #3

The facility failed to ensure medications were administered as ordered for one resident. Specifically, a supply of testosterone 1% gel was found to be depleted, with only 9 packets remaining from a March 2025 supply, despite documentation indicating daily administration through August 2025.

The facility failed to ensure medications were administered as ordered for one resident. Specifically, while records showed daily administration of testosterone 1% gel, an observation revealed a box of medication from March 2025 was still on hand, indicating the medication was not being administered as prescribed.

The facility failed to maintain all prescription and non-prescription medications under locked security when not under the direct physical supervision of a staff member.

The facility failed to ensure that 3 out of 6 personal care staff members had successfully completed the required 25-hour training program and competency evaluation. Personnel records for Staff A, D, and E lacked documentation of personal care service hours or competency evaluations.

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The facility failed to ensure that 3 of 6 personal care staff members had successfully completed the required 25-hour training program and competency evaluation. Personnel records for Staff A, D, and E lacked documentation of personal care service hours or competency evaluations.

The facility failed to ensure at least one staff person on the premises at all times had completed a CPR and choking management course within the last 24 months. Specifically, Staff F's CPR training had expired in August 2015, and there was no documentation of current certification in their personnel record.