Food Storage and Personal Hygiene Deficiencies: A Cook was observed preparing food without required hair or beard covering, and multiple food items in the freezer, refrigerators, and kitchenette were found without open dates. Surveyors also found expired Greek yogurt in the walk-in refrigerator. The CDM stated items should be labeled with open dates and expired items discarded, while the facility policy required food service staff to wear a hair net or appropriate hair covering during food production and clean-up.
Improper Thawing of Frozen Chicken: Staff thawed frozen breaded chicken in a 3-compartment sink without cold running water instead of using an approved defrosting method. A Cook said she removed the chicken from the freezer about an hour earlier, and the DM confirmed the chicken was thawed in the sink after staff forgot to remove it from refrigeration earlier. The facility's policy required thawing in refrigeration, under running water, in a microwave under specific conditions, or as part of the conventional cooking process.
Failure to Notify PCP and Family of Significant Weight Loss: A resident experienced significant weight loss after admission, with weights showing a marked decline over time and no weight-loss interventions in the care plan. Nursing and dietary notes documented continued monitoring and notification of the RD, but there was no documentation that the PCP or resident representative was notified about the 9.2% loss in 30 days, and the record lacked further weight-related follow-up.
A resident with severe dementia and behavioral symptoms received Seroquel with multiple dose increases, but the orders did not include a documented diagnosis to justify use or escalation. The chart showed dementia, agitation, and later psychosis documentation, while staff described the resident as generally directable and pleasant with more evening behaviors. The resident also had falls during the stay, including one that led to ER transfer.
Incorrect MDS Coding for Catheter Status: A resident’s MDS was coded as if the resident used a catheter and had urinary leakage, but the TAR had no documentation or physician orders supporting catheter use. The resident stated no catheter had been used since admission, and the MDS Coordinator acknowledged the assessment was coded incorrectly and that the resident did not currently have a catheter.
RN Coverage Not Maintained on Scheduled Shifts: The facility failed to ensure an RN was present for 8 consecutive hours each day. Review of schedules and timecards showed LPNs covered the shifts on two dates when no RN was scheduled, and staff interviews confirmed the facility had difficulty hiring nurses and relied on last-minute coverage. The facility reported a census of 49 residents on one date and 50 residents on another, including 3 residents receiving Medicare skilled services.
Missing Discharge Summaries: The facility failed to ensure required discharge documentation, including the recapitulation of stay, was completed for 3 discharged residents. Records contained transfer/discharge reports and/or signed discharge instruction forms, but no recapitulation of stay was located. The Administrator stated the EHR was not configured to generate the document, and the DON confirmed there was no policy for discharge documentation.
MDS assessments for 5 of 5 sampled residents incorrectly coded bed rails as physical restraints in Section P. Care plans either did not mention restraints or identified turn rails for bed mobility and transfers, while the MDS Coordinator stated she marked yes whenever side rails were present and that about 15 residents had been coded this way. The DON stated the facility had no residents using restraints or alarms and did not have a policy for MDS accuracy.
Delayed Toileting and Incontinence Care: A resident with intact cognition, urinary and bowel incontinence, and max assist needs was left in a wet brief and later found sitting on a urine-soaked wheelchair cushion. Staff reported the resident had called for bathroom help during lunch, but assistance was delayed until after dining room duties, and the DON stated residents should be changed every 2 hours and assisted before meals when they request toileting.
Medication cards for two residents were mixed up when an RN sent a resident home with another resident's full med cards during a leave of absence. The family reported the wrong cards accompanied the resident and contained multiple doses, and the RN stated the cards were in the wrong slot in the med cart and were not triple-checked before being sent out. The DON and Administrator described differing practices for preparing meds for leave, including use of bubble packs or sending full med cards.
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