Unsafe Room Temperatures During Heat Wave: Multiple residents were found in hot, uncomfortable rooms during a summer heat wave, with room temperatures measured above 81°F and several residents reporting sweating, dryness, and discomfort. The Ombudsman reported complaints about heat, the MD and ADM confirmed elevated room temperatures with an infrared gun, and the MD acknowledged the temperature logs did not capture hotter afternoon conditions. Residents with cognitive impairment and one resident with ALS were among those affected, and care plans already identified risk for dehydration and impaired skin integrity.
A facility failed to follow up on ordered psych consults for five residents after behavioral incidents and abuse allegations. Residents with diagnoses including dementia, psychosis, depression, and neurologic conditions were involved in assaults or reported being hit, and SS staff sent referrals by email but did not confirm whether the psych providers saw the residents. The MRD later stated the provider did not see the patients as scheduled, and the consult notes were not found in the system.
A resident with dementia, depression, and anxiety was seated in the dining room while other residents ate, but the lunch tray was not served with the group on two occasions. In a separate event, an LVN administered oral meds to another resident with intellectual disability and cerebral palsy in the dining room while wearing gloves, rather than in a private setting, which staff stated was not the facility’s practice and could be seen as disrespectful.
Failure to Offer Advance Directive Option: The facility did not provide the option to formulate an advance directive for five sampled residents. Records showed several residents were informed of the right to develop an advance directive, but documentation did not show the option was actually offered to the resident or RP. One resident had capacity to understand and make decisions, yet the social services assessment documented that no advance directive was in place, the opportunity was not offered, and no educational materials or state form were provided. Interviews with residents and SSD staff confirmed the omission.
Inadequate Water Temperatures in Shower and Sink Areas: Residents in Hallway A reported that shower water was too cool and that adjoining restroom sinks provided only cold water at night. A Maintenance Director measured one shower at 97.2 F to 100.1 F and another at 100.2 F to 106.7 F, while CNAs and an LVN stated the sink water stayed cold during the overnight shift and was used for bathing, hand hygiene, and incontinent care.
The facility failed to manage pain according to physician orders for several residents. One resident received acetaminophen for pain rated above the ordered mild-pain range and without documented nonpharmacological interventions, two residents received hydrocodone-acetaminophen when their pain scores did not match the ordered parameters, and another resident lacked an order covering moderate pain levels. Staff interviews and MAR review confirmed the medications were not always administered as ordered.
Food was not prepared to preserve nutritive value for 233 of 237 residents receiving kitchen-prepared meals. Vegetables, including pureed green peas, were cooked more than an hour before meal service and held in a steamer set at 212 to 220 degrees Fahrenheit. The Dietary Manager and an Assistant Cook confirmed the timing and holding conditions, and the facility policy stated fruits and vegetables were to be cooked to a holding temperature of 140 degrees Fahrenheit.
Kitchen Sanitation and Food-Contact Surface Deficiencies: The facility failed to keep the microwave clean, failed to air dry a blender and pitchers before storage, and had multiple dirty or damaged utensils and cutting boards with residue, fuzzy films, cracks, chips, and deep grooves. The Dietary Manager verified the findings during the kitchen tour.
Incomplete and inaccurate resident record documentation: Surveyors found that several resident records did not match the documented care or resident directives. One resident’s POLST left the Health Care Agent section blank despite an advance directive naming an agent, another resident’s opioid overdose monitoring entries used Y/YES in a way that did not align with the order’s required documentation, an IV antibiotic dose was not documented as given, and a physician progress note was dated after a resident had already been transferred to the hospital.
Infection control practices were not maintained for a decorative water fountain, laundry equipment, shower room caulking, and a glucometer. The fountain had visible green residue and lacked documented monthly monitoring, two washers had residue inside, Shower Room A had black residue on the caulking, and an LVN used a glucometer without disinfecting it before or after checking a resident’s blood glucose and returned it to the med cart unsanitized.
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