The Reserve at Mills Farm Villa #3

The facility failed to administer a narcotic pain reliever (morphine) and a narcotic anti-anxiety medication as ordered by a hospice provider for one resident. Specifically, there was no documentation of scheduled morphine doses being administered between March 21, 2023, and March 23, 2023, despite the medication being available on hand.

The facility failed to notify the physician for fingerstick blood sugar (FSBS) readings less than 100 as ordered for one resident. Specifically, the facility administered insulin despite blood glucose levels being significantly below the required threshold of 100. This failure occurred across multiple dates in November and December 2022.

The facility failed to ensure proper referral and follow-up for a resident's health care needs. Specifically, the facility did not notify the physician regarding finger stick blood sugar readings that were less than 100, as required by the resident's medical orders.

The facility failed to ensure medication was administered as ordered for 1 of 3 sampled residents. Specifically, the Medication Aide did not administer scheduled Novolog insulin when blood sugar levels were below 100 because they were following unauthorized verbal parameters requested by a family member. This practice placed the resident at risk for hypoglycemia or hyperglycemia.

The facility failed to provide adequate supervision for a resident with a history of falls. Specifically, a resident was found on the floor in another resident's room, and staff members were unable to recall the incident or the notification process during interviews.

The facility failed to provide adequate supervision for a resident with a history of falls. Specifically, following a fall on 11/18/20, there was no documentation of the required 30-minute to hourly checks for the subsequent 72 hours as mandated by facility policy.