Kitchen food storage and sanitation deficiencies were identified when unlabeled and undated fruit cups and pies were found in the refrigerator, the ice scoop holder and microwave had visible residue and food buildup, and raw beef was stored above a prepared salad mixture on a utility cart. Staff and the DM acknowledged that prepared foods should be labeled and dated, equipment should be kept clean, and raw meat should be separated from ready-to-eat foods to prevent cross-contamination.
Surveyors found that resident rooms and shower areas were not maintained in a clean, comfortable, and homelike condition. Observations showed dust, cobwebs, debris, peeling wallpaper, damaged doors, and dirty or broken wall AC units in resident rooms, while shower rooms had leaking ceilings, wet and warped flooring, missing and cracked tile, damaged walls, and shower heads wrapped with coban. Residents and staff confirmed several of the issues, including a broken door, dust blowing from an AC unit, and a shower head that was broken and difficult to use.
The facility failed to complete and document discharge planning for two residents. One resident's record did not clearly document the discharge reason, the discharge location was inconsistent across records, and the EMR did not show the reconciled med list and care plan as part of the discharge documentation. For the other resident, the care plan was not updated to reflect a preference to transfer to another SNF, and the EMR lacked documentation of discharge preparation in a form the resident could understand.
Pest Control Program Failed to Control Mice and Insects The facility did not maintain an effective pest control program to keep the LTC building free of mice, spiders, and other insects. Surveyors observed an open kitchen alleyway door, a gap under an exterior exit door, spiders in hallways, and traps in resident rooms containing spiders, bugs, and mouse droppings. Residents reported spiders on beds and walls, mice in rooms and hallways, and mouse droppings in rooms, while resident council minutes showed the mouse problem had continued for months. Pest control invoices repeatedly noted open doors and door gaps, but those issues remained unresolved in the observations reviewed.
Improper medication labeling, expired drugs, and unsecured storage were found in the facility. Surveyors observed expired diphenhydramine and milk of magnesia, eye drops and insulin pens without open dates, and multiple bottles of latanoprost and Refresh Tears without required labeling on a medication cart. Surveyors also found a medication closet and a storage room left unlocked, with heparin syringes, IV fluids, and other supplies stored in areas accessible from resident hallways.
Failure to Monitor Long-Term Antibiotic Use: A resident with CKD and recurrent UTIs was receiving daily cephalexin for UTI prophylaxis, but the facility did not document a clear rationale or effectively monitor the ongoing antibiotic use. Staff interviews confirmed the IP could not find supporting documentation, an RN did not know why the resident was on antibiotics, and the NP noted the resident had been educated about MDRO risk but refused to stop the medication; no urology documentation was found.
Incomplete neurological monitoring after a resident’s unwitnessed fall with head injury. A resident with dementia and other chronic conditions fell beside the bed, developed a forehead hematoma and facial bruising, and later reported head pain. Required neuro checks were missing across multiple shifts, and when the resident refused parts of the assessment, there was no documentation that the MD was notified.
Residents reported and audits confirmed repeated delays in call light response, with waits ranging from 15 to 60 minutes and some residents stating they waited 30 minutes to 2 hours for help. The facility’s policy required call lights to be answered as soon as possible and no later than 5 minutes, yet multiple residents described difficulty finding staff, especially at night, and staff interviews acknowledged the response-time problem.
The facility failed to report alleged abuse and an injury of unknown origin to the State Agency for three residents. One resident reported an LPN yelled at her and got in her face over pain meds, another resident with severe cognitive impairment was witnessed in a sexual act with his guardian and the report was delayed, and a third resident had an unexplained facial bruise that was not reported within the required timeframe.
Failure to protect a resident from resident-to-resident physical abuse occurred when one cognitively intact resident struck another resident in the face after being told not to enter the room. The injured resident had a swollen cheek, facial pain, and bruising under the eye, while the other resident had a documented history of wandering into peers’ rooms, seeking cigarettes, and taking items. The behavior care plan did not include interventions for that specific pattern of room entry and theft-related behavior, and the incident was not substantiated despite the physical injury.
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