Food portions were not served per recipe directions when a cook prepared sandwiches, pureed items, cake, and side items by estimation instead of measured amounts. The cook used tongs to add unmeasured meat, onions, and cheese to buns, served visibly different cake portions, and confirmed there were not enough pickles for all residents. The cook stated the portions were “eye balled” and that the spoons were inconsistent.
Kitchen Food Storage and Hand Hygiene Failures: Surveyors observed multiple expired, undated, unlabeled, and unsealed food items in dry storage, coolers, and freezers, and the RD confirmed staff were only marking opening dates rather than all required food dates. During meal prep, Cook-I repeatedly failed to perform hand hygiene before and after glove use and handled food, utensils, equipment, and surfaces with the same gloves or bare hands while preparing resident meals.
NA Training and Dementia Education Deficiency: The facility failed to ensure an NA received the required 12 hours of annual education and dementia management training as required by the Facility Assessment. Records showed the NA had only 10.15 hours of continuing education, no documented dementia training, and did not attend staff in-services or nursing meetings; the FA and DON confirmed the missing training documentation.
The facility failed to document and offer nonpharmacological treatment options when obtaining consent for psychotropic medications for several residents. A resident with PTSD, anxiety, and depression; a resident with severe cognitive impairment and dementia; and two residents with dementia-related behaviors received antipsychotic, antianxiety, and/or antidepressant medications, and consent forms were completed, but the records did not show that alternate treatment interventions were presented. The DON confirmed the facility had no evidence that these options were provided with the psychotropic medication consents.
Failure to Test Symptomatic Residents for COVID-19: The DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and was relying on physician direction or surveyor request. One resident with dementia, diabetes, and HTN had fatigue, cough, and lethargy before a COVID test was finally obtained; another resident with CAD, HTN, kidney disease, and vascular disease had a prolonged cough, congestion, weakness, and fatigue without evidence of testing; a third resident with severe cognitive impairment, HF, kidney disease, diabetes, and dementia had cough, sore throat, low O2 sat, fever, wheezing, and lethargy before testing was done.
A resident’s CCP was not updated after an oxygen order changed from 3 LPM to 4-5 LPM, and two other residents’ CCPs did not reflect self-administration of medications. One resident with schizophrenia had multiple meds ordered for bedside storage or unsupervised self-administration, but the CCP had no related focus or interventions. Another resident with dementia and diabetes was observed self-administering insulin even though the CCP only addressed staff administration.
A resident with moderate cognitive impairment, type 2 DM, and dementia self-administered Insulin Lispro even though there was no order or care plan documentation for self-administration. An LPN verified the medication, prepared the insulin, and handed the syringe to the resident, who injected it near the elbow. The DON confirmed no competency assessment had been completed.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Failure to maintain comfortable temperatures in common areas: surveyors found the dining rooms, hallway, lobby, and kitchen at or above 81 F, with the kitchen reaching 86 F while outdoor heat index conditions were very high. Staff reported the chiller had failed the prior year, the roof unit serving the kitchen and dining room had gone out the prior week, and portable AC units were being used in hallways and dining areas; a resident said bingo was too hot and humid and hard to breathe.
Food Temperatures Not Checked Before Meal Service: Dietary staff failed to check and record food temperatures before service, and some items were served below the required hot-holding temperature. A cook prepared multiple menu items, placed them in the steam table, and plated meals without verifying all items in the steam table; a test meal showed cauliflower at 127.0 F and pork chop at 129.2 F. On another meal service, a cook checked some items but not others, and a resident reported the chicken strip was not hot and was tough.
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