Food Items Left Unlabeled and Undated: The facility failed to properly label and date food products in the main kitchen's standing cooler rack and dry storage area. A Dietary Supervisor confirmed that three chef's salads, seven sandwiches, and an opened container of chicken gravy/bouillon were not labeled or dated, even though the salads were from the prior evening's dinner meal and should have been labeled and dated.
Food items were found stored beyond their use dates in the main kitchen and two kitchenette refrigerators. Surveyors observed expired dry goods, prepared foods, dairy items, lunch meat, horseradish, and an opened med pass supplement, and the Dietary Manager, an LPN, and an RN confirmed the items should have been discarded.
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
Failure to Hold and Notify Residents of Care Plan Conferences: The facility did not conduct required care plan conferences or ensure advance notification to the resident or resident representative for three residents. One resident with DM, HTN, and CAD, one resident with HTN, HF, and DM, and one resident with insomnia, anxiety, and ALS all had missing quarterly care conferences, and one resident stated he had only attended one conference since admission and had not been invited to others.
The facility failed to document that necessary resident information was sent with three hospital transfers, including care plan goals, advance directive information, ongoing care instructions, and resident representative information. It also failed to notify two residents or their representatives of the bed-hold policy and failed to notify the State LTC Ombudsman for three hospital transfers. The DON and Regional Director of Clinical Services confirmed the missing documentation and notifications.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Inaccurate bedrail care plans and missing ongoing assessments were identified for three residents. Two residents had bilateral enabler bars observed on their beds, but their last enabler-restraint assessments were outdated, and one resident had bilateral enabler bars with no order or ongoing assessment in the record. The residents had diagnoses including HTN, Parkinson's disease, depression, hyperlipidemia, and hemiplegia, and the facility policy required risk evaluation for bed rail use.
The facility failed to complete annual performance evaluations for three nurse aides. Personnel record review showed each aide was hired on 7/1/23, and none of the three files contained the required yearly performance evaluation. The NHA confirmed the missing evaluations during interview.
The facility failed to provide evidence that MRRs were reviewed by the attending physician for three residents. One resident with HTN, Parkinson's disease, and anxiety had an MRR recommending a GDR of quetiapine, but the record only showed a CRNP note without physician response. Another resident with DM, MS, and depression had multiple MRRs citing missing PRN details, stop dates, and pain reassessment, and a third resident with HTN, anxiety, and arthritis had an MRR noting multiple antidepressants and recommending evaluation for a single agent; in both cases, staff confirmed there was no evidence the attending physician reviewed the MRRs.
Medication carts and a resident room had multiple storage and labeling deficiencies. An RN left a medication cart unlocked and unattended, a narcotic drawer on another cart was unsecured, and a third cart contained unopened insulin that was not refrigerated before opening plus multiple insulin pens, inhalers, and eye drops with no open date noted. Two bedside eye drop bottles in a resident room were also unlabeled.
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