Unclean Resident Rooms and Evidence of Pest Activity: Two residents were found in rooms that were not maintained in a clean, homelike condition. One resident with severe cognitive impairment had a strong urine odor in the room and closet, while another resident with intact cognition reported mice coming out of the closet at night; the closet contained clutter and debris that appeared to be mouse droppings, and a pest control report documented two mice in the employee break room.
The facility failed to timely notify the provider of significant changes in condition for two residents. One resident with a complex cardiac history had a pulse of 131 bpm documented, but the elevated HR was not reported or reassessed for hours before the resident was later sent to the hospital with SOB and chest pain and died there. Another resident with ESRD on dialysis and cirrhosis with ascites had a 28.6-lb weight gain, but the record did not show provider notification of the significant change.
Staff failed to prevent significant medication errors for multiple residents. A resident with moderate cognitive impairment had Eliquis discontinued but the supply was not removed from the cart, 12 tablets were unaccounted for, and the resident later had severe bleeding with critically abnormal labs before dying in the facility. Other residents experienced repeated missed or incorrect insulin administrations, and one resident with bacteremia had delayed IV penicillin doses while awaiting medication from the infusion center.
Missed Ordered Laboratory Testing: The facility failed to obtain multiple ordered labs for several residents, including PT/INR monitoring for a resident transitioning from Eliquis to Coumadin with a Lovenox bridge, urinalyses for residents with suspected UTI/CAUTI, CBC/CMP testing, anticonvulsant levels, blood cultures, and an ammonia level. One resident developed active bleeding with critically abnormal lab values and died in the facility while bleeding from multiple sites. The record also showed several ordered tests were not found or were not completed as ordered.
Failure to Protect Resident from Sexual and Physical Abuse: A resident with dementia, PTSD, and a trauma history was involved in two separate incidents with other residents. In one event, a cognitively intact resident was observed on the resident’s bed with his penis exposed while the resident was holding his penis; the resident later had no recollection of the incident. In another altercation, two residents were seen fighting in the dining room, and the resident was left with scratches, bruising, and a fracture of the right 4th metatarsal after a wheelchair-related injury.
A resident with significant cardiac history had a documented HR of 131 and low BP, but an LPN did not notify a provider or document a repeat assessment for hours. The resident later developed SOB, chest pain, and low O2 sat, was sent to the hospital, and died there the same evening. The report also found an RN competency assessment with multiple below-standard scores that lacked required reassessment and completion documentation.
Misappropriation of controlled medications occurred when staff could not account for missing oxycodone for several residents and liquid hydromorphone for another resident. One resident was severely cognitively impaired and others were cognitively intact or moderately impaired, with orders for scheduled opioid pain meds. Pharmacy records, MARs, and narcotic counts showed missing tablets, incomplete documentation, and a liquid opioid that appeared to have been replaced with water.
Multiple residents with cognitive impairment, mobility limitations, incontinence, or dependence for bathing lacked documented showers, bed baths, or personal hygiene care despite care plans calling for scheduled bathing and assistance. Records showed blank or not attempted entries, missing ADL sheets, and limited shower documentation, and one resident stated staff shortages meant showers were not always provided. Staff interviews confirmed the gaps were documentation holes and no other way was known to verify the care.
Staff failed to follow multiple provider orders for residents’ meds, monitoring, and treatments. Missed items included pulse ox checks, accuchecks, BP checks before hydralazine, a PPD, ordered meds such as buspirone, lidocaine patch, oxycodone, insulin, hydralazine, sodium chloride, and Aldactone, plus ordered weights, an abdominal binder, a urology consult, and shift pain reassessments. Documentation also showed several ordered interventions were not completed or were not recorded as required.
The facility failed to properly account for controlled substances and to ensure ordered meds were available for administration. Surveyors found mismatches between narcotic count sheets and MARs, missing documentation for Oxycodone and Suboxone, and large quantities of Oxycodone that could not be accounted for. Surveyors also found that ordered meds such as Scopolamine, Glycopyrrolate, Suvorexant, sildenafil citrate, and Phenylephrine were not available when needed, resulting in missed or held doses.
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