A facility failed to keep resident rooms within the required temperature range after the HVAC system was shut off for repair. Four residents with respiratory conditions and/or O2 therapy were found in rooms measuring 85 to 90 degrees, and each stated that the rooms were hot or uncomfortable. Maintenance staff said contractors were working on the HVAC, and the admin said she was unaware the system had been turned off or that rooms were excessively warm.
Failure to prevent and manage pressure ulcers: Two residents developed pressure injuries that were first identified at advanced stages. One resident with multiple mobility and nutrition-related diagnoses had conflicting admission skin documentation and later was found with an unstageable left buttock pressure ulcer, while staff and the wound physician stated the wound was first assessed later and not clearly documented earlier. Another resident with dementia, DM2, HTN, incontinence, and limited mobility was admitted with intact skin but later developed a sacral opening that progressed to a stage 3 pressure wound.
A resident with pain orders and moderately impaired cognition had an oxycodone blister pack found tampered with, taped closed, and partially replaced with loratadine tablets. Staff who completed the narcotic count did not inspect the pack for tampering when signing off the count, and another LPN failed to sign the narcotic logbook with the outgoing nurse during a controlled substance count.
An LPN involved in a missing narcotics incident returned from suspension and worked a shift without documented education on drug diversion and narcotics reconciliation. The incident involved an Oxycodone IR 5 mg pack that appeared tampered with, with Loratadine tablets substituted for Oxycodone and five tablets missing. The DON and Staff Development/Educator acknowledged the education should have been completed before the LPN resumed work.
Failure to provide required discharge notification: A resident with arthritis, osteoporosis, DVT, UTI, and a hx of falls was discharged without written notice to the resident and rep at least 30 days in advance. Staff interviews showed the nursing team was not aware of the discharge until the day it occurred, the social worker did not follow the usual discharge process, and there was no documented MD discharge order in the record.
A resident admitted with psychosis, anxiety, and major depressive disorder had an incomplete PASARR I that failed to identify a history of serious mental illness or document whether a PASARR II referral was needed. The care plan stated Level II PASARR was not needed, and the DSW later acknowledged the PASARR I was completed incorrectly and that a new PASARR I and PASARR II referral would be submitted because of the resident's mental health diagnoses.
A resident with dementia and multiple chronic conditions had an unwitnessed fall, but ordered post-fall neuro checks were not documented as completed and the care plan interventions for floor mats on both sides of the bed were not consistently in place. Another resident with a left buttocks DTI/unstageable pressure ulcer had wound treatment orders, but staff did not develop a care plan for the wound. The DON acknowledged the missing wound care plan, and staff reported issues with eHR documentation and floor mat placement.
A resident with cataracts, dry eyes, and hypertensive retinopathy was seen by ophthalmology, and the physician recommended cataract surgery. Although pre-op testing and clearances were completed, staff did not follow up with the physician to schedule the surgery, and the ADON said this was an oversight.
Facility staff failed to properly sanitize chinaware plates and silverware, with food particles still present on multiple plates and utensils after dishwashing. Staff also stored an opened case of Ensure in a med storage room beyond its use-by date, with seven bottles unaccounted for; an RN Unit Manager acknowledged the findings.
A resident with dementia, CKD, COPD, urinary retention, edema, and unsteadiness had a physician order for OT to evaluate decreased ability to feed herself, but no documented OT evaluation was completed. The family and legal guardian raised concerns about communication and feeding ability, the DON emailed OT to request the eval, and the DOR later stated the resident was delayed behind new admissions without informing the family, Administrator, or DON.
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