Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Inaccurate resident assessments were identified for multiple residents when MDS coding did not match the clinical record, observations, or staff statements. One resident was coded as having a restraint-related chair device despite no restraints being observed or ordered, another was coded as not receiving antibiotics despite MAR documentation of mupirocin use, and two other residents had missing or incorrect MDS entries for diagnoses, ROM status, and skin/wound conditions based on admission records, physician notes, wound care documentation, and staff interviews.
PASRR assessments were not updated for two residents after new mental health diagnoses were documented. One resident had records showing brief psychotic disorder, major depressive disorder, and later delusional disorder, with psychotropic orders for quetiapine and trazodone, while the PASRR did not reflect mental illness. Another resident had documented depression and anxiety, later behavioral health notes identifying major depressive disorder and decline-related concerns, and an escitalopram order for depression, but the PASRR also did not reflect mental illness.
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
Failure to Provide Ordered Nutritional Supplement: A resident at risk for malnutrition did not receive a physician-ordered frozen nutritional treat with lunch and dinner. Observations showed the meal trays contained food and drinks but no supplement, and the resident stated she was not getting any frozen nutrition treat. Staff interviews revealed the order was not communicated to the kitchen program and was not appearing on the meal ticket; the kitchen manager said changes depended on nursing communication, and the DON said the CDM typically ensured items were on the tray.
Missing Oxygen Order and Improper Nebulizer Storage: A resident receiving oxygen for sleep apnea had no physician order specifying the oxygen delivery rate, even though staff were setting the rate. In a separate observation, a resident’s nebulizer mask was left unbagged on the nightstand while not in use. An LPN and the DON both stated respiratory equipment should be stored in a bag when not in use, and the facility policy required bagged storage between uses.
Unlabeled medication cups and supplies were left unattended at the bedside of two residents. A CNA stated cream was left in one resident’s room and later applied, while another resident had a clear cup with a spoon and cream on the nightstand. Staff confirmed neither resident had an order to self-administer medications, and an LPN and the DON stated the residents did not have self-administration orders. The facility policy required medications and biologicals to be stored in locked compartments.
Unsafe food storage was identified in the main kitchen and in 1 of 2 nourishment rooms. The walk-in freezer had no stand-alone thermometer, and the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit with 7 thawed ice cream bars stored inside. The Kitchen Manager acknowledged the missing thermometer and confirmed the thawed items.
Improper Garbage and Refuse Disposal: Surveyors observed a large lidless dumpster containing exposed facility trash bags and a small dumpster with an open lid exposing its contents to pests and wildlife. The Kitchen Manager acknowledged the conditions, and the Interim Certified Dietary Manager stated the large dumpster was a construction dumpster and should not have contained facility trash.
A resident receiving PT had multiple scheduled therapy sessions with no documentation in the service log matrix. The resident said therapy had been inconsistent, and the DON of Therapy acknowledged missed sessions without recorded reasons, stating the therapist should have documented why the sessions were not completed. The resident later said he had missed therapy when he was not feeling well and that the therapist had been sick once.
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