A facility failed to accurately code MDS assessments for multiple residents. Documentation showed one resident had a Stage 3 pressure ulcer, a surgical wound, and wound treatments that were not captured; another resident’s admission MDS missed glaucoma, hyperparathyroidism, and scheduled pain treatment; a third resident’s annual MDS missed a diuretic and anticoagulant; and a fourth resident’s quarterly MDS incorrectly coded corrective lenses as no despite documented and observed use of glasses.
A resident's dignity was not maintained when staff left a breakfast tray uncovered in the resident's room despite the resident's stated preference to have the meal covered when not eating. The resident was observed asleep while multiple flies landed on the uncovered food, and a GNA said the resident had refused to allow staff to remove the tray.
Resident wheelchairs and a reclining geriatric chair were observed in disrepair, including torn vinyl, missing foam padding, and missing armrests. Staff described an inconsistent repair reporting process, with verbal reports to the charge nurse, unit manager, ADON, or DON, while the DOM stated there was no specific wheelchair process and that housekeeping or staff would sometimes submit work orders or report issues informally.
The facility failed to timely report an alleged abuse involving a resident found restrained by a sheet and an alleged misappropriation involving another resident’s missing money. Staff accounts showed the abuse concern was not reported to OHCQ within 2 hours, and the missing funds concern was not reported within 24 hours. The NHA stated the abuse allegation should have been reported immediately, and staff had only completed a grievance form for the missing money.
Incomplete Annual MDS Assessment: A resident’s annual MDS was incomplete because cognition and mood were not assessed. The record showed no BIMS score and no assessment of memory, recall, or daily decision-making skills, and the mood section was also left blank. The issue was identified during review of an incident in which the resident alleged money had been stolen from a wallet, and the MDS Coordinator stated the sections were assigned to social work but the assessment window was missed due to staffing issues.
Failure to provide grooming and personal hygiene services for a dependent resident. The resident, who had a stroke and was coded as dependent for personal hygiene on the MDS, was observed unshaven with long untrimmed fingernails and black debris under the nails on more than one occasion. The care plan included weekly grooming, beard shaving, and nail trimming, but the resident remained unkempt and stated he should not have to beg for the care.
A resident with prostate cancer did not receive Nubeqa timely. The resident and RP reported the medication was given late over the weekend, and the MAR audit showed the 8 AM dose was administered hours late on one day and again late the next day, with the 5 PM dose given only 1 hour and 36 minutes later. The DON confirmed the untimely administration.
Failure to Follow BP Hold Parameters for Antihypertensive Medications: A resident with hypertensive heart disease received ordered BP medications despite BP readings below the physician's hold parameter of systolic BP less than 100. The MAR showed Isosorbide Mononitrate ER, Losartan, and Atenolol were administered when BP was 86/54, 94/57, and 77/52, and the DON confirmed the medications were given when the ordered parameters were not met.
Unlocked medication and treatment carts were found unattended on multiple units, allowing surveyors to access resident medications and treatment supplies. The surveyor observed opened Lidocaine with no date opened, two opened bottles of 0.9% sodium chloride irrigation that were not dated, and two unlabeled medication cups containing pills. An LPN stated she had left one cart unlocked while responding to a dialysis patient, and the DON was informed of the concerns.
A resident’s breakfast was served with pancakes at 110 degrees, below the stated hot food standard of 135 degrees, and the tray did not include the milk listed on the meal ticket. The resident and RP reported that coffee and milk were often missing and that breakfast food was frequently cold.
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