Riverwood Assisted Living Facility

The facility failed to ensure physician notification for a resident following medication refusals of an antipsychotic and a psychotropic medication. Specifically, for Resident #1, there was no documentation that the Mental Health Provider was notified regarding multiple instances of mirtazapine refusal recorded in October and November 2023.

The facility failed to ensure physician notification for a resident's refusal of antipsychotic and psychotropic medication. Specifically, the electronic medication administration record showed no documentation of mirtazapine administration for 31 out of 31 opportunities during October 2023.

The facility failed to ensure physician notification for medication refusals for 2 of 5 sampled residents. This included failures to notify providers regarding refusals of various medications, including an inhaler, insulin, and psychotropic medication.

The facility failed to ensure physician notification for medication refusals for 2 of 5 sampled residents. Specifically, the facility did not document that the primary care provider was notified regarding multiple refusals of medications including an inhaler, insulin, and psychotropic medication.

The facility failed to ensure that a medication aide had completed required training on the care of diabetic residents prior to performing fingerstick blood sugars and administering insulin. A review of personnel records for a rehired staff member showed no certification of training, despite documentation showing the staff member performed these tasks 33 times in April 2023.

The facility failed to ensure that 1 of 2 sampled medication aides had completed required training on the care of diabetic residents prior to performing fingerstick blood sugars and administering insulin. Specifically, a re-hired medication aide's personnel record lacked certification of this training despite documentation showing they performed insulin administration and blood glucose monitoring multiple times in April and May 2023.

The facility failed to ensure that a licensed health professional support (LHPS) competency validation checklist, including return demonstrations, had been completed for tasks such as checking fingerstick blood sugar (FSBS) and administration of oxygen.