The facility failed to follow physician and therapy orders for several residents. A resident received insulin even though the blood sugar was below the hold parameter, another resident was observed with a straw despite a no-straw diet order, and eye drops were administered inconsistently with the order. The facility also did not ensure wound dressing orders were entered when wounds were found, and it lacked evidence of ordered I&O monitoring and weekly weights for another resident.
Kitchen sanitation, food storage, and equipment monitoring failures: Dirt and food debris were observed on kitchen and dish room floors, and the mixer had visible residue. Multiple food items in the reach-in refrigerator were expired, unlabeled, or improperly stored, including staff-owned food. Dish machine wash/rinse temps and sanitizer PPM were not documented for multiple meal periods, and several refrigerator/freezer logs had missing entries. The food prep sink and ice machine air gaps were not plumbed to code and were dirty, the garbage disposal was not working, and a cook was observed preparing food without facial hair protection.
A resident with multiple psychiatric and physical diagnoses rolled out of bed while a CNA was changing bed sheets and was later found to have a fractured left humerus. The CNA said the resident was a one-person assist and rolled over too fast for her to stop, and there was no evidence of safety interventions such as positioning away from the bed edge or using a pillow or device to stabilize the resident during the turn.
Failure to report injury of unknown origin: A resident was found to have a fractured left humerus after an ED visit for abdominal pain/possible constipation, following an earlier fall out of bed that had shown no shoulder injury on x-ray. The DON did not consider the fracture related to the prior fall, did not file an incident report with Licensing, and there was no evidence the injury was reported to Licensing and Certification or APS.
Failure to Investigate Injury of Unknown Origin: A resident later found with a fractured left humerus had previously fallen out of bed, but the DON did not consider the fracture to be related and did not investigate it as an injury of unknown origin. The resident reported the injury occurred while rolling out of bed during personal care, and the facility policy required such injuries to be reported and investigated.
A resident room had a strong urine odor, a stand fan heavily covered in dust, dirty floors, and a disorganized appearance. The room also had large black markings on the wall next to the bed, and the DON confirmed the findings.
A resident’s care plan was not revised to match current transfer needs. The resident and a staff member stated the resident only needed contact guard assist with 1 staff member standing by, but the Kardex and care plan still listed transfers as totally dependent with 2 staff assists. Therapy notes also showed the resident was a contact guard assist for all transfers, and the care plan had not been updated to reflect this.
Failure to Provide Personal Hygiene and Nail Care: A resident who was dependent on staff for ADL assistance was observed with unclean hands and long, jagged fingernails with a dark substance under and around the nails. Record review showed the resident needed substantial assist from 1 staff member for personal hygiene, including nail care, and the DON confirmed the findings during interview.
Physician Block Orders Not Signed During Required Visits: A resident’s provider completed progress notes during multiple required regulatory visits, but the physician block orders for meds and tx were not signed on the visit dates. The orders were signed days later after each visit, and the DON confirmed the finding during interview.
A resident with a history of chronic constipation and right hemicolectomy had no documented BM for 10 days, despite scheduled Miralax and PRN sorbitol orders. The facility did not fully implement the constipation protocol or document provider notification when interventions were ineffective. The resident later transferred to the ED for abdominal pain and constipation and was hospitalized with a 7.9-cm rectal fecal impaction and stercoral colitis requiring disimpaction; the DON acknowledged the lack of documentation that the provider was notified.
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