Failure to Protect Resident from Sexual Abuse: A cognitively intact resident reported that another resident approached her from behind in the dining room, made a sexual comment, and touched her breast. The other resident later admitted the contact. Records showed he had a history of sexually inappropriate comments and wandering into other residents’ rooms, and he had a care plan for sexual inappropriateness with redirection and monitoring interventions.
Housekeeping staff failed to follow infection control practices while cleaning resident rooms. In one room, a housekeeper cleaned the sink and toilet area without hand hygiene or glove changes when moving between dirtier and cleaner areas, did not wait the required dwell time for the toilet disinfectant, and did not clean high-touch items such as light switches, door handles, the call light, or closet handles. In another room, a housekeeper used the same gloves and rag across the sink area, closet door and handles, bed area, bedside table, and resident personal items. Leadership and the IP confirmed that staff should clean from cleaner to dirtier areas, perform hand hygiene and glove changes, and clean high-touch surfaces during room cleaning.
A resident with NASH, hepatic encephalopathy, and CKD developed confusion and disorganized thinking, but the nurse did not complete a timely change-of-condition assessment, obtain transfer-time VS, or notify the NP/MD when EMS was called. The resident’s representative reported worsening AMS and pain, while the hospital later documented severe AMS with elevated ammonia. The facility also held ordered rifaximin because it was pending pharmacy delivery/back order, with no doses given and no documentation that the provider was notified that the antibiotic was unavailable.
A resident with severe dementia and aggressive behaviors struck another resident in the face with a closed fist after the second resident returned to the dining room and tried to take food from the first resident’s plate. Both residents had severe cognitive impairment and histories of physical and verbal aggression, and the victim’s care plan noted food insecurity and the need to offer snacks or an alternate plate when others were eating. Staff separated the residents after the assault, and the victim later could not recall who hit him.
Failure to Supervise a Resident at Risk for Elopement: A resident with dementia, TBI, and chronic respiratory failure had escalating exit-seeking behavior and impaired judgment, yet was able to elope from a secured courtyard gate and later through an office window without staff awareness. After the first elopement, the resident was missing for days before being found by EMS on a highway and was treated for a hip fx, elbow fx, pneumonia, and other medical issues. The record also shows a later elopement after repeated attempts to leave the building.
A facility failed to maintain a safe, clean, and comfortable environment when resident rooms and common areas remained excessively hot for months, with multiple readings in the 80s and residents reporting sweating, discomfort, and poor sleep. Surveyors also found soiled linens, urine odors, stained bedding, dirty toilets, and unclean room conditions, while staff said linens were changed mainly on shower days. In addition, a staff member’s dog was allowed in the building without complete vet records or required parasite/heartworm prevention, and the dog barked at residents and visitors while being informally monitored by staff.
Failure to assess clinical appropriateness for self-administration of meds. A cognitively intact resident with CHF, COPD, OSA, and other diagnoses was observed with pills left at the bedside, but the care plan and self-medication assessment only approved nasal spray and cough drops. Staff could not find an order allowing self-administration of the resident’s prescribed meds, yet medication was still left at the bedside and taken without clear verification.
A resident with hemiplegia and hemiparesis had bedside bed rails and a transfer pole removed from his room, despite needing assistive devices for bed mobility and transfers. He reported frustration, difficulty repositioning in bed, and a fall after sliding out of bed while trying to move himself. OT and staff noted he transferred more effectively with the transfer pole than with a sit-to-stand lift, and the corporate nurse consultant said the devices were removed to avoid a potential regulatory citation without prior evaluation or risk-benefit review.
Incomplete Investigation and Care Planning After Resident-to-Resident Assault: The facility did not thoroughly investigate a physical altercation between two residents or document a clear root cause for the assailant’s sudden aggression. A resident with dementia, TBI, and behavioral disturbance struck another resident in the face, but the event details were inconsistent across records and interviews, and the psychiatric recommendations were not fully reflected in the care plan. The victimized resident had severe cognitive impairment, used a wheelchair, and had trauma-informed care needs, yet her care plan did not identify specific trauma triggers or comprehensively address her risk for resident-to-resident abuse.
Two residents using BIPAP and CPAP had respiratory care deficiencies involving missing or incomplete physician orders, absent care plan focuses, and unsanitary equipment storage. One resident’s BIPAP lacked orders for therapy settings and cleaning, and the mask was observed draped on a bedside commode and hanging in the bucket. Another resident’s CPAP lacked restarted cleaning orders and a sanitary storage order, and the mask and tubing were observed hanging off a dresser with the mask touching the floor.
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