Meal tickets and the menu did not match the food actually served. Surveyors observed that a resident with intact cognition and several other residents did not receive items listed on their tickets, including soup, salad, pineapple, English muffins, and pudding. The FSD said soup was not offered during summer months per company policy, and the Dietitian should have updated the tickets; Staff F acknowledged the mismatch, and the DON said the discrepancies had been an ongoing concern.
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not provide written notice, including the reason, before room or roommate changes for six residents. Residents with intact cognition, as well as residents with dementia or other cognitive impairment, and several resident representatives reported they were not notified in writing. The DON acknowledged the facility did not give written notification when room or roommate changes occurred.
A facility failed to complete ongoing reassessments of bed siderail safety for a resident with severe cognitive impairment and total dependence for bed mobility. The resident continued using the siderails for months without the required review, and later developed bruising and a traumatic posterior shoulder dislocation after the arm was reportedly caught in the rail. An internal investigation and later assessment found the siderails were unsafe and no longer indicated.
Failure to Report Suspicious Serious Injury: A resident with severe cognitive impairment and total dependence for bed mobility developed bruising to the arm and a traumatic shoulder dislocation after an unexplained incident. The injury was not witnessed, the resident could not explain it, and the Administrator acknowledged the event was suspicious, but there was no evidence it was reported to the proper authorities, including the State Survey Agency.
Failure to Thoroughly Investigate an Unexplained Injury: A resident with severe cognitive impairment and total dependence for bed mobility was found with bruising to the right armpit and posterior arm and later diagnosed in the ER with a closed traumatic posterior shoulder dislocation. Staff did not initiate a thorough investigation, no witnesses were identified, direct care staff were not interviewed for statements, and the facility's records did not show a complete investigation of the injury of unknown origin.
The facility failed to complete and document a comprehensive facility-wide assessment for resident care needs during routine operations and emergencies. The 2025 Facility Assessment was signed by former leadership, referenced a missing Staffing and Personnel Worksheet, listed prior admin and DON staff, and contained multiple sections stating no records were found. The facility also could not provide evidence of a plan to maximize recruitment and retention of direct care staff, and the DON acknowledged the assessment did not accurately reflect staffing patterns.
A resident returned from the hospital after possible seizure activity with discharge instructions for neurosurgery follow-up, but the appointment was not scheduled and there was no record that the resident or representative declined it. In a separate issue, staff documented a foot cradle order as completed for another resident, yet surveyors observed the blankets resting on the resident’s legs and feet instead of being offloaded by the device, and staff acknowledged the order was not properly carried out.
Unsafe water temperatures were found at resident-accessible sinks and bathrooms across multiple floors, with readings above the safe range and a mixing valve set too high; staff were unsure of safe bathing temperatures, and water temperature logs had not been completed for months. In a separate event, a resident with dementia and a traumatic subdural hemorrhage was found prone on the floor bleeding from the face after an unwitnessed fall, then lifted back into bed despite the facility fall policy requiring a full head-to-toe assessment and minimal movement unless there was a life-threatening concern.
Failure to notify the MD/NP of significant changes in condition affected two residents. One resident on hospice developed worsening fever, tachycardia, labored breathing, and lethargy, but staff did not report the decline to the provider. Another resident developed urinary retention requiring catheterization, but the facility did not obtain a provider order or notify the practitioner, and the resident was later hospitalized for urinary retention.
Failure to Administer Hospice Morphine as Ordered: A resident on hospice with pneumonia and respiratory failure did not receive ordered Morphine for pain and SOB in a timely manner. Hospice documented worsening distress, including tachypnea, tachycardia, fever, lethargy, and labored breathing, while the MAR showed missed scheduled and PRN doses. Staff reported the medication was unavailable, did not verify EMD inventory before the doses were due, and did not notify the provider, even though the Morphine was later found in the facility's emergency supply and EMD inventory.
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