Richmond Hill Assisted Living #2

The facility failed to promote residents' active involvement with each other, families, and the community. Observations and interviews revealed that many scheduled activities on the monthly calendar did not occur, and staff did not engage residents in activities unless specifically asked.

The facility failed to ensure residents were treated with dignity and respect. Specifically, five resident bathrooms were found to be without available paper towels, forcing residents to use toilet paper to dry their hands.

The facility failed to promote residents' active involvement with each other, families, and the community. Interviews and observations revealed that many scheduled activities on the monthly calendar did not occur, leaving residents with little engagement. Additionally, staff members were responsible for activities in the absence of an activity director but failed to implement the scheduled program.

The facility failed to ensure that one of three sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) prior to hire. Specifically, there was no documentation in the employee's personnel record to prove an HCPR check was completed before their start date.

The facility failed to ensure proper referral and follow-up for the health care needs of residents. Findings included failure to notify prescribers of missed medication doses, failure to send laboratory results to the pharmacy, and failure to report low blood sugar levels or obtain ordered monthly weights.

The facility failed to ensure that one of three sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) prior to hire. There was no documentation available in the personnel record to prove an HCPR check was completed before the employee's start date.

The facility failed to ensure proper referral and follow-up for two sampled residents. Specific failures included not notifying a prescriber of missed clozapine doses, failing to send complete laboratory results to the pharmacy, failing to report low fingerstick blood sugar levels, and failing to obtain ordered monthly weights.

The facility failed to ensure medication administration was in accordance with physician orders for one of three sampled residents. Specifically, Resident #3 did not receive their prescribed Caplyta for schizophrenia because the facility ran out of medication samples and failed to ensure a new supply was available. Additionally, staff documented the medication as administered on 06/14/22 when it was actually unavailable.

The facility failed to administer medications as ordered to a resident diagnosed with schizophrenia. Specifically, the resident did not receive his prescribed Caplyta for several days because the facility lacked sufficient medication samples to provide during his leave of absence.

The facility failed to ensure necessary medical referrals and follow-up care for residents. Specifically, the facility did not notify a mental health provider regarding three Emergency Department visits for suicidal ideation and missed scheduled appointments for audiology and wound care.

The facility failed to ensure necessary referrals and follow-up care for residents to meet their routine and acute health needs. Specifically, the facility failed to notify a mental health provider regarding three Emergency Department visits related to suicidal ideation and missed scheduled audiology and wound care appointments.