Cold Main Dining Room Temperature: The facility failed to maintain comfortable and safe temperatures in the main dining room, which was repeatedly reported by residents as cold during meals. Observations found residents using coats and blankets in the dining room, and measured temperatures were below the facility’s 71 to 81 degree range, including readings of 68.6 degrees, 66.8 degrees, and an air vent blowing 46-degree air into the room.
A resident with severe cognitive impairment was physically assaulted by another resident who also had severe cognitive impairment and a care plan for aggressive behaviors toward others. In the atrium, after the resident asked the other resident to move away, the other resident pushed the resident in the abdomen, causing a fall, wrist pain, swelling, bruising, unresponsiveness, and ER-confirmed fractures of both distal radii and the ulna styloid; an LPN and CNA witnessed the event, and the DON stated staff were expected to redirect and follow care plans.
Failure to notify a resident representative of a change in condition: A resident with severe cognitive impairment, Alzheimer’s dementia, DM, and urinary incontinence developed a coccyx wound that was treated and monitored by nursing staff, but the resident’s representative was not notified before the wound was discussed at the care plan conference. The wound care nurse, the representative, and the DON all confirmed the lack of prior notification.
Failure to protect a resident with severe cognitive impairment from physical abuse by another resident. A resident with a history of agitation and physical aggression punched another resident in the face multiple times and attempted to wrap the resident's O2 tubing around the resident's neck after a confrontation near the wheelchair. Staff intervened before the tubing was placed around the neck, and the assaulted resident had redness to the cheek while the aggressive resident had broken skin on the knuckles.
The facility failed to provide enough nursing staff and did not maintain adequate CNA coverage across multiple shifts. The DON stated the schedule was built with 2 nurses per shift and a minimum CNA pattern, but survey review of PBJ data, worked schedules, and staffing declarations showed repeated shortages, including shifts with only 1 CNA overnight and other shifts with 2 to 3 CNAs. Residents and the resident council reported long call light times, delayed or missing food delivery, and difficulty getting clothing changed, and a CNA reported feeling overwhelmed by low staffing.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge notices before hospital transfers for multiple residents. The DON stated that an Interact form was sent with residents and bed-hold information was provided, but confirmed that residents or their representatives were not given the required written notice. The facility policy required a Resident Notice of Transfer or Discharge with specific information, including the reason for transfer, destination, and Ombudsman contact information.
Failure to provide bathing per the care plan for two residents. One resident who needed max assist for bathing was observed in a hospital gown with greasy, uncombed hair, and the bathing log showed missed baths and one refusal. Another resident with amputation, impaired balance, and pain was also observed with greasy, uncombed hair, and the bathing log showed limited showers despite a scheduled shower preference. CNA and DON interviews confirmed CNAs and nurses were expected to provide bathing, with no scheduled shower aides.
A facility failed to provide individualized activities of preference for several residents and did not provide weekend activities. Residents reported limited or no meaningful activity options, with one resident saying the activities were for children, another saying there was nothing to do, and a representative stating a resident liked to keep hands busy but did not participate much. Records and observations showed sparse one-to-one and group participation, no documented weekend activity participation, and no weekend activities scheduled, while staff acknowledged residents needed 7-day activity support and that weekend assistance was lacking.
Food Quality and Meal Delivery Concerns: Residents reported bland, repetitive, and sometimes unidentifiable food, small portions, extreme temperatures, and late or missing meal trays. Resident council minutes and grievance logs showed repeated complaints about food quality, tray timing, and unmet preferences, but there was no evidence of pattern tracking, meal observation, or documented dietary interventions to improve the issues.
Survey results and plans of correction for the prior 3 years were not available for review upon request. Observation of the State Survey binder showed only a 1-year public record document, an iQIES ePOC, and a complaint survey, with no notice of prior surveys, despite a framed sign stating 3 years of results. The administrator stated she was unaware the last standard survey needed to be posted in the binder.
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