A resident with obesity, impaired mobility, and anticoagulant use was injured during incontinent care when a GNA continued pulling a brief after the resident complained of pain and did not remove the plastic fastening tabs first. The tab cut the resident’s left posterior thigh, causing uncontrolled hemorrhage, EMS transport, hospitalization, and blood product transfusions.
Dignified Dining Not Maintained on Dementia Unit: Staff were observed standing while feeding residents and serving seated residents at different times instead of together. During meals, some residents waited while others ate, and one resident had a fly near the head and food. The dining area also had crumbs, spills, and trash on the floor, and the NHA and DON acknowledged the dignity concerns.
Surveyors found multiple maintenance and housekeeping issues, including water-stained ceiling tiles, missing or damaged room fixtures, exposed drywall, a broken wheelchair armrest, and trash and food debris in a unit dining area. A resident with dementia was also observed in a room without a sheet on the bed, with ant and roach spray on the bedside table, and the UM confirmed the spray belonged to the family and that the bed had been cleaned earlier but not yet made up.
The facility failed to follow infection control practices after a complaint and surveyor observations found dirty meal trays, dried brown liquid, a stained pillow, and food debris in resident areas. Multiple bathrooms had unlabeled basins, bedpans, fracture pans, and urine collection items stored on floors, under sinks, or on toilets without plastic wrapping, and one bathroom had a fly on the toilet rim. The Chase Unit TV room also had numerous spills, crumbs, paper towels, cups, food pieces, and trash on the floor. The IP stated the facility did not have a policy for storing these items.
Failure to maintain an effective pest control program was cited after surveyors observed numerous flies throughout the facility, including in resident rooms, bathrooms, dining areas, and around resident food. An IP confirmed the fly problem, and the DOM acknowledged the facility had a fly issue despite routine pest control visits and prior logs showing fly activity throughout the building.
Failure to timely report an alleged abuse involving a resident who said a CMA withheld meals until medication was taken. A PTA heard the concern, but did not report it immediately after the first occurrence and only told management after the resident repeated the allegation. Interviews also reflected the resident reported the issue to staff and police, while the NHA learned of it from rehab staff.
Facility staff failed to administer a resident’s morning Pantoprazole and Synthroid timely. The resident, who had dementia and orders for Pantoprazole for GERD and Synthroid for thyroid, was scheduled for 6 AM dosing, but the meds were repeatedly given hours late on multiple occasions. The DON confirmed the late administration during interview.
Failure to Provide Ordered Pressure Ulcer Treatments: Staff failed to administer ordered skin prep for a resident’s boggy heels on multiple occasions and did not follow Wound NP orders for an unstageable sacral pressure ulcer. The wound care orders were not implemented as prescribed, and the treatment frequency was reduced from BID to once daily.
A resident admitted with muscle wasting and atrophy had documented weight changes from 164 lbs to 178.6 lbs, then dropped to 156.6 lbs, triggering a Dietitian note for significant weight loss and a reweight request. The reweight was delayed, the resident was later documented at 153 lbs, and no further Dietitian follow-up or additional nutritional interventions were put in place after the weight loss was identified; staff also did not follow the facility’s weekly weight monitoring schedule for newly admitted residents.
Incomplete and inaccurate resident records were identified for three residents. One resident had abuse allegations involving a CMA, but the chart lacked documentation of the allegations, police interview, and related psych note details. Another resident had an unwitnessed fall with a brow laceration, but neuro checks were missing from the chart and were kept in the DON’s office file. A third resident with impaired cognition and severe BIMS score was on a locked dementia unit, yet elopement risk assessments incorrectly scored the resident as not at risk.
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