The facility failed to provide enough nursing staff to meet resident needs, with staff and residents reporting frequent short staffing, long call light delays, missed showers, and rushed care. During meal observations, a resident spilled food while waiting for help, another could not reach a breakfast tray until a NA repositioned them, and a resident with a paralyzed arm had the tray placed on the wrong side. The report also cited inadequate wound care for a resident with a surgical hip wound and a pressure injury that developed in the facility.
A facility failed to keep 4 hallways clean and comfortable, with stained carpets, food debris, urine odor, and cluttered resident rooms observed. Residents reported rooms were not cleaned routinely, one said a spill was left sticky after being wiped but not mopped, and a grievance showed food spills remained for days before cleaning. Staff said housekeeping could not always complete daily room cleaning and that staffing was limited.
A resident admitted after a hip hemiarthroplasty had ordered surgical wound assessments and daily dressing changes, but the record showed missed dressing changes after showers and missing wound documentation, including wound characteristics, measurements, and appearance. Staff interviews confirmed the hip dressing could get wet during showers, that nursing should have assessed and documented the wound after wet dressings, and that the wound care orders were not clarified or followed as expected.
Failure to Provide Bed-Hold Notice at Hospital Transfer: The facility did not provide the required written bed-hold notice when three residents were transferred to the hospital. Records showed one resident had a broken leg, anxiety, and vision loss with impaired cognition; another had metabolic encephalopathy, kidney disease, and severe cognitive impairment; and a third had respiratory failure, diabetes, and heart failure with intact cognition. Transfer records and interviews with two representatives confirmed the notices were not received, and the DON stated the process was not followed.
A hydration deficiency occurred on the dementia unit when 11 residents did not have a water pitcher or any fluids available at their bedside after lunch trays were collected and before the evening shift returned clean pitchers. The Unit Manager acknowledged the facility's hydration process, but confirmed the residents had no water available in their rooms at the time of observation.
A facility failed to consistently serve meals according to resident meal tickets, dislikes, and preferences. One resident received the wrong breakfast and a lunch tray without a meal ticket, while other residents were served eggs, chicken, bacon, or missing fruit despite those items being crossed out or listed as dislikes. Dietary staff and CNAs reported that meal tickets were not always followed on the tray line, and the DNM acknowledged that some staff needed additional training.
A resident with broken leg healing, anxiety, vision loss, and moderately impaired cognition became unresponsive and was transferred to the hospital after not responding to verbal stimuli. The RN notified the provider and DON, but the resident’s representative/emergency contact was not notified of the change in condition or transfer. The representative later said they only learned of the hospitalization from the hospital, and the DON stated the notification process was not followed.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
Failure to Investigate Reported Falls: A resident with intact cognition had two reported fall incidents, including an unwitnessed fall and a fall reported after returning from home, but neither incident was entered on the incident log. Staff and the DON stated that self-reported falls should be assessed and investigated to determine reporting needs, root cause, and whether abuse or neglect occurred, but the facility did not investigate the later fall and could not rule out abuse or neglect.
Failure to investigate and document a resident-to-resident abuse allegation involving two residents. One resident reported that another resident intentionally bumped their wheelchair after becoming upset, but the event was not documented in the medical record or incident logs, and no full investigation was completed. The residents involved had significant care needs, including depression, anxiety, pain, memory impairment, altered mental status, and wheelchair use, and staff acknowledged the allegation was not fully investigated or documented.
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