Inn at Library Way

Based on review of employee records and interview, the facility failed to ensure their unlicensed direct care employees received skills training completed by a Licensed Practical Nurse (LPN) or a Registered Nurse (RN). This had the potential to affect all 79 residents in the facility.

Findings include:

Review of employee records for Resident Assistants (RA) #353 (date of hire 07/02/25), RA #345 (date of hire 05/01/25), and RA #256 (date of hire 05/01/25) revealed a document titled 'Nursing Assistant Job Skill Training Checklist' with trainer signatures completed by a fellow resident assistant. RA #353's was signed on 07/03/25, RA #345's was signed on 05/08/25, and RA #256's was signed on 05/06/25.

Interview with Business Office Director (BOD) on 09/04/25 at 1:05 P.M. clarified Resident Assistant and Nursing Assistant were the same positions, and the titles were used interchangeably. BOD confirmed the 'Nursing Assistant Job Skill Training Checklist' in RA #353's employee record was signed by a trainer who was not an LPN or a RN.

Interview with Director of Nursing (DON) on 09/04/25 at 1:53 P.M. confirmed the 'Nursing Assistant Job Skill Training Checklist' in RA #345's and RA #256's employee record were signed by a trainer who was not an LPN or a RN. The DON further stated they were not aware the training needed to be signed off by someone who was an LPN or RN. She confirmed the one who signed all the forms was another unnamed resident assistant.

Based on observation, staff interview, and medical record review, the facility failed to ensure a resident received medications as ordered. This affected one (#10) of two residents reviewed for medication administration. The facility census was 70.

Findings include:

Review of Resident #10's medical record revealed an admission date of 10/20/22, with diagnoses including heart failure, mild cognitive impairment, and hypothyroidism.

Review of Resident #10's physician's orders dated 09/16/24 revealed she was to receive levothyroxine, propranolol, digoxin, and aspirin one time a day.

Review of Resident #10's Medication Administration Record (MAR) revealed levothyroxine was scheduled at 5:00 A.M. daily. It was not administered on 11/02/24, 11/04/24, 11/06/24, 11/07/24, 11/08/24, and 11/11/24. Resident #10's propranolol, aspirin, and digoxin were scheduled for 7:00 A.M.

Observation on 11/12/24 at 10:11 A.M., revealed Licensed Practical Nurse (LPN) #142 administering medication to Resident #10. Including her levothyroxine, propranolol, aspirin, and digoxin.

Interview on 11/12/24 at 10:11 A.M., with LPN #142 verified Resident #10's medication were administered late.

Interview on 11/12/24 at 3:13 P.M., with the Administrator verified Resident #10's levothyroxine was missing several doses being administered.

Based on staff interview and record review, the facility failed to ensure staff received annual fire safety training. This had the potential to affect all 70 residents residing in the building.

Findings include:

Review of fire safety documentation revealed no evidence any staff received annual fire safety training.

Interview on 11/12/24 at 3:35 P.M., with the Administrator verified they had not completed the required annual fire safety training.