Resident Face Shown in Staff Social Media Video: The facility failed to ensure a resident was free from abuse when a CNA posted videos on social media while working, and one video briefly showed the resident’s face. The Administrator confirmed the video included the CNA complaining about her assignment and showing facility hallways and the resident, who had severe cognitive impairment and diagnoses of anxiety and depression. Staff stated that taking or posting resident photos or videos on social media was a violation of abuse, privacy, and resident rights.
Inadequate supervision during nightly smoking activities was identified when a resident who was supposed to wear a fire-resistant apron and be supervised was observed smoking outside at night without the apron and with no staff present. Other residents reported that staff did not come out to monitor smoking in the courtyard at night, and observations showed multiple residents smoking in a dark courtyard area with minimal lighting and no staff present. Interviews also indicated that some residents drank alcohol, became intoxicated, or passed out while outside smoking, despite the facility policy requiring supervised smoking by staff.
Improper Storage and Cleaning of Bedpans in Shared Bathroom: A resident’s shared bathroom had a bedpan stored directly on the floor and another uncovered bedpan stored in an armoire, along with wet underwear on the sink ledge and stained non-skid strips and toilet surfaces. Staff interviews confirmed bedpans should be bagged and not placed on the floor or furniture, and the facility policy required bedpans and urinals to be stored in a clean disposable bag between uses.
Failure to protect a resident from physical abuse occurred when two cognitively intact residents got into a verbal argument that escalated into a physical altercation near the smoking area. One resident alleged the other grabbed her by the throat and pushed her against a wall, while staff observed the residents yelling, cussing, and overturning each other’s rollators, with one resident appearing to push the other. The incident was documented as a resident-to-resident abuse allegation.
A resident with significant mobility dependence and intact cognition developed bilateral buttock/coccyx friction injuries during routine care. The care plan identified risk for skin breakdown and directed staff to avoid shearing during positioning, turning, and transfers, but the resident later had partial-thickness friction/shearing wounds with purple, red areas and blood blister-like findings. Staff and the DON believed the injury occurred during brief removal, sheet handling, or pulling the resident up in bed.
Failure to Provide Scheduled Showers: A cognitively intact resident with orthopedic aftercare, Charcot's joint, and an external fixator was dependent on staff for ADLs and had a care plan for showers on a set schedule. Record review showed multiple missed or undocumented showers, incomplete shower sheets, and no documentation supporting the claim that the resident could not shower because of the external fixator. Progress notes also reflected the resident and his friend complained about not receiving showers, while the DON said the resident often refused showers and an LPN described the facility's refusal-signature process.
Unaccounted Resident Oxycodone: The facility failed to ensure a resident’s Oxycodone was properly accounted for after the pharmacy delivered 30 tablets for pain management. An LPN reported receiving the medication, placing it on a dresser at another LPN’s direction, and signing the controlled substance tracker as if it had been handed off, but the tracker did not document the Oxycodone and the facility could not account for the missing medication.
Failure to develop care plans for IV/PICC line care, urinary catheter use, and constipation risk. Two residents had invasive lines or catheters and prolonged periods without bowel movements, while one resident also received narcotic pain meds and the other had orders for bisacodyl and PICC/IV dressing care. The current care plans did not address these needs.
Failure to provide ordered bowel management and wound care: one resident had prolonged constipation with no documented bowel sounds assessment, delayed physician notification, and incomplete bowel documentation; another resident’s ordered wound treatment was not signed out on the TAR; and a third resident had no documented BM for days, no constipation care plan, no physician notification, and a missed PRN suppository order.
A resident receiving IV NS for dehydration had gaps in IV initiation, flush orders, and site monitoring. An RN observed blood in the tubing, flushed the line without cleaning the port, and replaced the bag and tubing, while the record showed missing documentation for IV initiation/discontinuation, no flush or dressing-change orders, and no documented insertion-site assessments during continuous infusion.
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