The facility failed to timely escalate a resident with signs of sepsis, respiratory distress, hypoxia, hypotension, and acute decline for hospital transfer despite NP and telehealth recommendations for immediate ED evaluation; the resident was later admitted with sepsis, obstructing kidney stone, and hypoxic respiratory failure. The facility also missed documentation for ordered wound care for one resident and administered PRN hydrocodone-acetaminophen to another resident without documenting the required pain level.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Food was not consistently temped before leaving the kitchen, and a test tray showed both hot and cold items served at improper temperatures. The DAM could not produce food temp logs, dietary staff only recorded four item temps before tray line, and a tray sent to a hall had a ham & cheese sandwich, coleslaw, lettuce and tomato, and mixed fruit all outside expected temp ranges. Residents also reported that room trays were often hot when they should be cold and cold when they should be hot.
Infection control lapses were observed with trash stored on the floor in soiled utility rooms and with missed hand hygiene during meal service. Residents did not receive hand sanitation during lunch pass, an LPN did not perform hand hygiene while helping with trays, and no resident or staff hand hygiene was completed during meal service on the 100 wing.
Care plan meetings were not consistently held or documented, and residents were not included in their own care planning. One resident’s care plan was also not revised after she was fitted for an upper denture and was awaiting delivery. The DON and DoSS acknowledged that care plan meetings were behind, and records showed missing quarterly reviews and no documented invitations or attendance for some residents.
Improper POST Form Consent for Resident Without Capacity: A resident with vascular dementia, major depressive disorder, hallucinations, unspecified mood disorder, and anxiety signed a POST form selecting CPR with full treatment even though a physician determined the resident lacked capacity to make medical decisions. The resident’s representative did not sign the form, and the DoA acknowledged the error during survey review.
Failure to document NOMNC delivery to a resident representative. For one resident sampled for beneficiary notification, Social Services completed the NOMNC verbally by phone, but the form had only one facility signature and there was no record that the notice was mailed to the representative. The DOSS confirmed the lack of documentation and stated the facility does not use certified mail.
PASRR Not Updated for New Mental Health Diagnoses: A resident with existing mental health diagnoses later developed PTSD and Major Depressive Disorder, but the facility did not update the PASRR or submit it for Level II review. The PASRR had listed anxiety, depression, and auditory hallucinations, and staff confirmed it needed to be updated after the new diagnoses were identified.
Failure to provide daily ambulation assistance after therapy discharge. A resident who had been discharged from PT with orders for daily walking with nursing assistance and a RW was documented as walking only once over three months. Staff interviews confirmed nursing staff were expected to assist with daily ambulation, but CNAs reported they did not regularly walk the resident and had not seen her walk.
Medication Storage and Labeling Deficiencies: An insulin pen for a resident was found in a med cart past its use-by date, and an LPN confirmed it should have been discarded. In a separate finding, a multi-use PPD vial in the med refrigerator had not been dated when first opened, despite facility policy requiring the opened date to be recorded and the vial insert stating it should be discarded after 30 days in use.
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