Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
Missing controlled medications and incomplete narcotic counts: Two residents had opioid medications missing from the narcotic drawer, including a hydromorphone bubble pack and a hydrocodone bubble pack, with related count sheets also missing. Staff interviews and narcotic logs showed shift-to-shift counts were not consistently completed or signed by both nurses, and staff reported that narcotic counts were often not done when carts changed possession. One resident had severe cognitive impairment and chronic pain, and the other had moderate cognitive impairment with acute pain related to fractures and dislocation.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
Failure to update lift recliner safety with cognitive decline: A resident with worsening BIMS scores and intermittent confusion, sundowning, and hallucinations was not given a formal safety assessment for her lift recliner despite changing transfer needs and staff/family reports of fluctuating cognition. Staff later found her on the floor in front of the recliner with the chair elevated; she sustained forehead and nose lacerations and a CT showed an acute C1 fracture.
A resident with severe cognitive impairment and a physician-ordered puree diabetic diet was given a peanut butter and jelly uncrustable during a snack pass after asking for more food. Staff later stated they did not know the item was not appropriate for a puree diet and that diet lists were not available to them at the time. The resident choked, became unresponsive, lost her pulse, and required CPR and EMS intervention; hospital records noted a small pneumothorax and rib fractures related to CPR.
An unlocked medication cart was found at the nurses' station with no staff present while residents were nearby in the dining/living area. The cart contained stock meds, prescribed meds for multiple residents, and other medications and supplies. An LPN later identified herself as the nurse assigned to the cart and stated she should have locked it before walking away. Facility leadership stated carts must be locked when not in use, and the policy required carts to be securely locked when out of the nurse's view.
Pureed Diet Menu Items Not Served: Seven residents ordered pureed diets were served lunch without the pureed wheat rolls listed on the approved menu. The cook verified the menu, pureed the broccoli and chicken, but forgot to puree the rolls, and all seven pureed trays were served without them. The CDM and Administrator confirmed the menu should be followed.
Food was served at temperatures below what residents expected and below the facility’s stated standard. Several cognitively intact residents reported warm foods were sometimes served cold or cooler than desired, and one resident said food lacked taste. During an observed breakfast delivery, hot items measured 118 degrees and 115 degrees after the tray was delayed and then delivered to the resident. The CDM and Administrator stated food delivered to residents should be at or above 135 degrees, and the policy required hot foods to be hot and cold foods to be cold.
Food Storage and Labeling Deficiencies: Surveyors observed multiple uncovered, unlabeled, and undated food items stored in the refrigerator, including trays with small plates and pudding-like substance, an unlabeled bag in a cereal bin, an undated bag of cheddar cheese, and unlabeled bags of green leafy items. An LPN/cook told the CDM the trays were not labeled at the start of the survey tour, and the CDM and Administrator acknowledged that stored food should be labeled. The facility policy required opened containers to be dated and sealed or covered during storage.
Unsafe food handling and cross-contamination occurred during meal prep and lunch service when a dietary staff member used the same pair of gloves throughout the observation while handling food, utensils, drawers, refrigerator doors, lids, bread, and serving items. The staff member touched food and surfaces repeatedly without changing gloves, including placing food into a blender, serving resident plates, retrieving sauce from a refrigerator, and handling bread and butter patties. The DM stated staff were expected to wash hands and change gloves after touching food or surfaces, and facility policy required safe hygienic practices to prevent contamination.
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