Richmond Hill Assisted Living #5

The facility failed to ensure that 8 of 8 dining room chairs were clean and in good repair. Observations revealed heavily soiled upholstery, visible foam material due to large tears in several chairs, and damaged wood finishes. Residents and staff reported that the chairs have been in poor condition for a long time.

The facility failed to ensure that lunch service was provided using non-disposable plates as required by regulation. Observations and interviews revealed that meals had been served on disposable plates for periods ranging from two weeks to 18 months. Staff indicated that disposable plates were used because clean dishes were still in the dishwasher, and some staff were unaware of the requirement for non-disposable place settings.

The facility failed to ensure that lunch service was provided using non-disposable place settings. During an observation, residents were served meals on disposable plates because the non-disposable dishes were still in the dishwasher. An interview with staff confirmed the use of disposable plates and a lack of awareness regarding the requirement for non-disposable service.

The facility failed to ensure medication was administered according to physician orders for Resident #1. Specifically, the facility administered incorrect dosages of warfarin and failed to document required INR lab work and updated orders. This error occurred across multiple instances between December 2023 and January 2024.

The facility failed to ensure medication was administered according to physician orders for Resident #1 regarding warfarin dosages. Specifically, the facility administered incorrect dosages and failed to document required INR lab work and updated orders across multiple dates in December 2023 and January 2024.

The facility failed to ensure medication aides observed residents actually taking their medications immediately following administration. This resulted in a resident holding back three doses of olanzapine and taking them all at once with the intent to commit suicide, and another resident having daily medications left unattended on a bedside table.

The facility failed to ensure medication aides observed residents actually taking their medications before recording the administration on the medication administration record. This failure was evidenced by one resident who was able to hold back multiple doses of medication for later use and another resident whose daily medications were left unattended on a bedside table.

The facility failed to ensure medications were administered as ordered for two residents. Specifically, Resident #3 was missing their prescribed dose of paliperidone ER, despite the eMAR indicating the medication had been administered as scheduled.