Riverside Villages Homes #3

The facility failed to ensure proper referral and follow-up for a resident's acute health care needs. Specifically, staff failed to notify the primary care physician when a resident's systolic blood pressure readings exceeded the ordered parameter of 150 on multiple occasions between February and April 2019.

The facility failed to maintain common areas, including the living room, dining room, bathrooms, laundry room, and hallway, in a clean and orderly manner. Findings included dirty/scuffed floor tiles, soiled carpeting, and a cluttered coffee table containing various items and a tool.

The facility failed to maintain living room and dining room furniture in a clean and good repair. Observations revealed heavily soiled and stained upholstery on the loveseat, couch, and dining chairs, as well as dining chairs that had been repaired with screws.

The facility failed to maintain hot water temperatures at three common bathroom sinks between 100 and 116 degrees Fahrenheit. Temperatures were observed as high as 130 degrees Fahrenheit, posing a significant burn risk to residents.

The facility failed to maintain hot water temperatures at the sinks in three common bathrooms within the required range of 100 to 116 degrees Fahrenheit. Specifically, temperatures were recorded as high as 122 and 130 degrees Fahrenheit. An employee admitted to increasing the water temperature for floor waxing and failing to turn it back down.

The facility failed to ensure medications were administered as ordered for one resident. Specifically, a Lidocaine topical patch 5% was not available for administration, and there was no documentation in the Medication Administration Record (MAR) for the prescribed patch. The facility was unaware the medication had not been delivered by the pharmacy and had not attempted to contact the physician for the required prior authorization.

The facility failed to accurately document the administration of Fosamax on the medication administration records (MAR) for one resident. Specifically, there was no documentation of the medication being administered during December 2014 and January 2015, despite the medication being available.

The facility failed to develop an individualized, written resident care plan within 30 days of admission for one resident. Specifically, Resident #3's care plan was missing from their record despite the resident having multiple diagnoses and experiencing two falls since admission.

The facility failed to develop a resident care plan in conjunction with the resident assessment within 30 days of admission for one of three sampled residents. Specifically, Resident #3's care plan was missing from the resident record despite a history of falls and significant medical diagnoses.

The facility failed to serve a required therapeutic diet as ordered by the resident's physician. Specifically, one of three sampled residents was not provided a diabetic, no concentrate sugars (NCS) diet as prescribed in their medical record.