Resident-to-resident physical abuse occurred when one resident, after complaining that another resident entered his/her room, shoved the wandering resident out into the hallway. The injured resident fell face down and sustained a laceration above the eye, bleeding, bruising, pain, and CT/X-ray-confirmed facial fractures. Witnesses, the ADON, CNAs, LPN, and the facility’s investigation all described the event as physical abuse.
Menu portion sizes were not followed for chopped and puree diet items when staff used a 3 oz spoodle, a #8 dipper, and a #12 dipper instead of the #10 and #6 dippers listed on the preplanned menu. An employee and the Dietary Supervisor both confirmed the utensils used did not match the menu, and the Dietary Supervisor said the shortage of serving dippers/scoops contributed to the issue and that residents could potentially be affected by weight loss.
Frozen Food Storage and Temperature Control Failure: The facility failed to keep food frozen solid in a reach-in bread freezer and failed to maintain proper cold holding temperatures. During a kitchen tour, items such as pancakes, French fries, onion rings, and hush puppies were soft to touch, and the freezer’s internal thermometer read 45 degrees F. A service invoice noted the condenser coils were completely clogged with dirt, and the Maintenance Director said the freezer went down because the A/C was broken and hot, humid air from the kitchen contributed to the coils clogging.
No Refrigerated Storage for Outside Food: The facility failed to provide a refrigerator area for food brought in by family or visitors, despite a policy allowing such items to be stored in the food service dept. The Dietary Supervisor said staff stopped the food at the door and had no room for resident food, and Resident Council members reported there was no place to store it, so it had to be thrown away or eaten the same day.
Improper Dumpster and Grease Refuse Area Sanitation: Surveyors observed trash debris around dumpsters, a heavy greasy buildup on the oil/grease refuse container, and a large fly concentration near the refuse area. Staff said Maintenance and Housekeeping shared responsibility for keeping the area clean, but the area was not maintained free of litter and attractants. Flies were also observed in the kitchen and a resident reported flies in his room, while residents in Council reported flies landing on food and disturbing sleep.
Inaccurate PBJ Staffing Data Submission: The facility failed to submit complete and accurate direct care staffing data to CMS for a quarter of PBJ reporting. The PBJ report showed an excessively low weekend staffing trigger, and the ADM stated she compiled the data, sent it to corporate, and a third-party company submitted it to CMS, while also acknowledging she did not know why the low weekend staffing was triggered.
The facility failed to keep several resident bathrooms in good repair and sanitary condition. Surveyors observed broken tiles and holes behind commodes, water-damaged walls, and dirty floors with urine in multiple bathrooms. The HSUP said the bathrooms were cleaned daily, but urine on the floor contributed to the condition and a floor replacement would be needed. Surveyors also observed brown spots in hallways and a fly near breakfast trays being removed from resident rooms.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
A resident with Type 2 DM had a physician order for BG checks before meals and at bedtime, with provider notification for readings above 250 mg/dL. The MAR showed multiple BG results above that threshold, but there was no documentation that the MD or other provider was notified. RN confirmed the order, the MD had no recollection or record of notification, and the DON stated there was no evidence the notifications occurred.
PASRR Level II Evaluation Not Completed Timely: A resident with PTSD and GAD had a PASRR Level I screening that identified the need for a Level II eval, but the required review was not completed when the resident was admitted. The SSD acknowledged the PASRR process was not completed as required and stated the omission was later identified during a chart update.
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