A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
A facility failed to plan group outings outside the facility for residents who said it was very important to them to go out in a group setting. Five cognitively intact residents on the Resident Council reported there had been no scheduled outings for over a year, and they described feeling sad, unhappy, lonely, or depressed because they could not go to restaurants, shop, socialize, or attend events like movies, bowling, Christmas lights, or parades. The AD and Administrator stated the facility had no van and relied on contract transport for medical appts only.
Medication error rate exceeded the 5% threshold when an RN administered two insulin doses to a resident with DM without priming the Lantus and NovoLog pens before each injection. Surveyors observed the RN give the ordered subcutaneous doses without completing the manufacturer-required safety test, and the RN stated she believed priming was only needed before first use. The DON and consultant pharmacist confirmed the pens should be primed before each dose.
Food items in the walk-in cooler were found with expired use-by dates, missing labels or dates, and signs of spoilage, including discolored lettuce and opened cheese products left improperly stored. Surveyors also observed pink and brown substances on the kitchen ice machine baffle above the ice trough. The Head [NAME] acknowledged the storage issues and that the ice machine needed cleaning, while the DDM and Administrator stated that food labeling, dating, spoilage checks, and ice machine sanitation were expected.
MDS assessments were inaccurately coded for falls and PASRR for multiple residents. One resident’s MDS did not fully reflect two documented falls, including one with a major injury, and several residents with documented Level II PASRR determinations were coded as not currently considered by the state PASRR process to have SMI/ID or a related condition. Staff interviews confirmed the chart contained the PASRR information, but the MDS entries did not match the record.
Missing Discharge Care Plan: A resident with OCPD and intact cognition did not have a discharge care plan despite care plan meetings discussing short-term stay, psychiatric services, and later transfer to a long-term psych facility. The comprehensive care plan had no discharge plan, and staff interviews showed confusion between the SW and MDS Coordinator about who was responsible for developing it.
The facility failed to submit Level II PASRR requests for two residents admitted with PTSD, depression, and anxiety diagnoses. Both residents had Level I PASRR screenings that did not document mental health diagnoses, while later psych notes showed active psychiatric conditions and treatment with antidepressants and anxiolytics. The SW confirmed she was responsible for PASRR re-evaluations and said the omission was an oversight.
Expired Vitamin B12 was administered to a resident after an MA gave a daily dose from a medication cart bottle that had an expiration date of 1/2026 and still contained 92 pills. During the med storage observation, the MA stated she had already given the expired dose that morning and admitted she did not check the expiration date before administration. The MAR confirmed the resident received the Vitamin B12, and the DON and Administrator stated their expectation was that residents receive non-expired medications.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
Unsecured Medication Cart and Expired Medications: An unlocked, unattended med cart was observed in a nursing station with open access, and expired Vitamin B-12 was found on another cart. An MA stated she administered the expired medication without checking the expiration date, while the DON said staff were expected to verify expiration dates and keep med carts locked when unattended.
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