Inaccurate MDS assessments were completed for two residents. One resident was coded with diabetes type II even though the record showed no orders, monitoring, treatment, or care plan interventions for diabetes, and staff confirmed the diagnosis was not actually present. Another resident was coded as needing isolation or quarantine for an active infectious disease, but the record contained no documentation of related care or services, and staff confirmed the coding was done in error.
Failure to Protect Residents from Abuse: Two residents with severe cognitive impairment were involved in a resident-to-resident altercation after screaming and yelling escalated to punching and slapping around the arms. An LNA removed one resident and reported the incident to an LPN, while the facility’s investigation documented that both residents were assessed with no injuries and no recall of the event; the Administrator confirmed the abuse incident occurred.
Care plans not revised after resident altercation. Two residents with severe cognitive impairment were involved in a physical altercation, with an LNA observing punching and slapping and notifying an LPN. Although both residents already had care plans addressing aggression or prior resident-resident conflict, no additional interventions were added after the incident, and the administrator confirmed the plans were not updated to reflect the event.
Narcotics were not properly documented and signed in for two residents. One nurse accepted multiple cards of oxycodone from the pharmacy but did not sign them in, and a count later showed one tablet missing from the cart. For another resident, an added supply of oxycodone was entered on the narcotic log with only one RN signature, and staff confirmed the sign-in process was not followed consistently.
A resident with dementia and difficulty walking was injured during a transfer when an LNA was reported to have been forceful, pushing the resident against a wall and causing the resident’s head and face to strike the wall and call light box. The resident cried, yelped, and sustained a skin tear and bruising while two LNAs attempted to assist with toileting and standing.
A resident at high fall risk with CVA, dementia, CKD, and vision deficits had repeated unwitnessed falls while assigned to rooms far from the nurses’ station, where staff could not reliably hear the call bells or visually supervise the area. The resident’s care plan was not consistently updated after multiple falls, some supervision interventions were cancelled, and the resident later suffered a fatal fall with SDH, cerebral hemorrhage, and multiple sinus fractures.
A resident with moderate cognitive impairment was mocked and ridiculed by two LNAs during incontinent care, with staff laughing and making insulting comments about the resident's yelling and behavior. In a separate incident, another cognitively intact resident was denied toileting assistance when an LNA allegedly dismissed the request, turned off the call light, and left the room, leading to incontinence and emotional distress.
Call Light Left Out of Reach: A resident with hemiplegia, hemiparesis, morbid obesity, right-hand contracture, and muscle weakness had a call bell repeatedly observed tucked on the side of the bed rail and out of reach while in bed. The resident stated the call bell could not be reached during most of the day shift, and a roommate had to ring for staff when incontinence care was needed. An RN and the DON confirmed the call light was out of reach.
Failure to timely report an allegation of staff-to-resident abuse involving a resident. The incident was not reported within the required 2-hour window, and the Admin confirmed the report was late and that she learned of it later from an internal incident report.
A resident with COPD, dementia, depression, anxiety, and a recent hip fracture had care plan interventions for skin breakdown risk, including turning and repositioning every 2-3 hours and use of a heel protector foot cushion with anti-internal rotation adaption wedge. However, the task record and progress notes contained no documentation that these interventions were implemented, LNAs reported no documentation of turning/repositioning, the UM said it was only documented on nights, and the DON stated the task was assigned but not documented. A facility turning/repositioning log also showed the resident remained in a wheelchair for 4-6 consecutive hours on multiple days with no repositioning documented.
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