The Reserve at Mills Farm Villa #1

The facility failed to ensure the Primary Care Provider (PCP) was notified of blood pressure parameters for a resident. Specifically, multiple blood pressure readings outside of the prescribed parameters were recorded in the resident's vitals, but there was no documentation that the PCP was notified of these readings.

The facility failed to ensure the Primary Care Provider (PCP) was notified of blood pressure parameters for a resident. Specifically, multiple blood pressure readings outside of the prescribed parameters (systolic < 90 or > 180) were recorded in the eMAR, but there was no documentation in the resident's record or confirmation from the PCP's office that the physician had been notified.

The facility failed to ensure sufficient staff were on duty to meet the supervision needs of a resident with gait instability and a history of falls. Specifically, the resident required supervision when ambulating, but staffing levels were inadequate to provide necessary oversight.

The facility failed to ensure medication administration records were accurate. Specifically, a resident missed 20 doses of Synthroid without documentation, and duplicate entries for cephalexin were found in the eMAR system.

The facility failed to ensure sufficient staff were on duty to meet the supervision needs of a resident with gait instability and a history of falls. This resulted in six unwitnessed falls for Resident #3 over a three-month period.