A resident with trach/vent dependence, PEG feeding, ESRD, and severe abdominal illness developed vomiting through the trach, abdominal distention, lethargy, and profound hypotension, but full VS were not documented and transfer to the hospital was delayed until after repeated interventions. The facility also missed skin integrity issues for two residents, including a heel wound and a scabbed abrasion linked to shear from lift-sheet/clothing handling, and an LPN was observed giving late morning meds while multiple residents were still highlighted as late on the EMAR.
Pressure ulcer prevention and wound care failures were identified for multiple residents. A resident with immobility and diabetes developed a facility-acquired sacral wound that progressed to an infected stage 4 ulcer requiring hospitalization and debridement, while surveyors observed missed wound vac documentation, stool-contaminated dressings, improper offloading, low air loss mattresses on static mode or incorrect weight settings, missing heel protectors, and a wheelchair resident without a pressure-relieving cushion.
Failure to maintain functional oxygen delivery: Two residents who required continuous O2 via concentrator experienced episodes where the equipment was not delivering oxygen as ordered. One resident reported SOB when the concentrator stopped working and staff temporarily used a portable tank before replacing the unit; another resident reported that the water canister was not attached properly, became unable to breathe, lost consciousness, and was later hospitalized after CPR was initiated. Staff interviews confirmed the concentrators were expected to be checked for proper function and that one RN found no oxygen flow during assessment.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to supervise a cognitively impaired resident at high risk for falls led to two unwitnessed falls on the same day. Staff were in other residents’ rooms when the resident fell in the hallway, and later the resident fell again in the dining/common area after attempting to stand from a wheelchair. Documentation was inconsistent about fall precautions and alarms, and one RN stated no VS or neuro checks were done before EMS transport. The resident was sent to the hospital and diagnosed with a spinal compression fracture.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Failure to Provide Nail Care During ADL Assistance: Multiple residents who required help with grooming and hygiene were observed with long, dirty, uneven fingernails and black/brown debris under the nails. Several residents stated they wanted their nails cleaned and clipped, and one resident with stroke-related R-sided weakness and hand contractures had overgrown nails, including nails digging into the palm. The DON stated nail care is part of grooming care, and one resident with multiple comorbidities and substantial/maximal assistance needs reported that no one offers to clean or cut his nails.
Inadequate catheter and perineal care was observed for multiple residents with urinary devices and incontinence needs. A resident with an indwelling catheter had cloudy urine, sediment, bleeding, pain, and an unsecured catheter after staff reportedly pulled on it during care. Other residents were found with urine- and stool-soiled clothing, bedding, and catheter dressings, leaking or dangling urinary tubes, delayed brief changes, and incomplete peri-care that did not include the full frontal perineum, labial folds, urethra, or catheter area.
Failure to Follow Hand Hygiene, Gloving, and EBP Practices: Staff repeatedly entered resident rooms without complete PPE, used the same soiled gloves across multiple care tasks, and failed to perform hand hygiene before, between, and after resident care. Observations included CNAs changing soiled linens for a resident on EBP without gowns, a nurse and CNA transferring another resident without gowns, a nurse entering a contact precautions room without PPE and then touching the med cart without hand hygiene, and wound care and incontinence care provided to multiple residents while wearing soiled gloves. A resident’s nephrostomy drainage bag was also observed in a basin on the floor and leaking urine.
Failure to Maintain Comfortable Room Temperatures: Several residents were found in hot, stuffy rooms with weak or nonworking AC units, and room temps were measured above 81 F, including one room at 89.5 F. Residents reported feeling hot and uncomfortable, and some were not offered a room change while the issue persisted. The facility did not follow its Hot Weather policy for relocating residents to cooler areas and monitoring room temps.
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