A resident with cerebrovascular disease, schizophrenia, and bipolar disorder received multiple scheduled meds by rectum even though the MAR ordered them by mouth and there was no documented change in route. Staff interviews and the facility investigation showed the nurse complied with the resident’s request to change the route instead of obtaining a provider order, and the event was documented as a medication error.
Staff failed to follow infection control practices during resident care and medication administration. An LPN gave insulin to a resident on EBP without a gown, another LPN picked up a glove from the floor and used it during eye drop administration, and staff used shared and resident-specific equipment, including BP cuffs and a glucometer, without cleaning or disinfecting between uses. A resident’s Foley catheter bag was also observed touching the floor.
Failure to perform hand hygiene during medication administration. An KMA did not sanitize hands after each resident medication pass, picked up a dropped Risperidone tablet with bare hands instead of discarding it, and administered medications to a resident without hand washing or hand sanitizing before or after. Facility policy required hand hygiene and infection control procedures during medication administration, and leadership stated staff were expected to clean hands between residents.
Failure to notify physician and guardian of missed antipsychotic injection and behavior changes. A resident with schizoaffective disorder, dementia with behavioral disturbance, and severe cognitive impairment missed a scheduled monthly Invega Sustenna injection, and the dose was not given until weeks later. The MAR and EMR showed no documented notification to the MD or guardian when the medication was missed, and progress notes later documented refusal of oral meds and increased anxiety and agitation without notification. The resident then had escalating psychotic and aggressive behaviors, multiple hospital transfers, and admission to a behavioral unit.
A resident with schizoaffective disorder, dementia, and severe cognitive impairment missed his scheduled monthly Invega Sustenna injection when the dose was documented as unavailable on the MAR. The injection was not given until 17 days later, and there was no evidence the restart dosing sequence was followed after the prolonged gap. After the missed dose, the resident developed increased anxiety, agitation, delusions, and aggressive behavior, requiring transfer to a hospital, then a state psychiatric facility, and later another hospital behavioral admission. Staff and the pharmacy director confirmed the facility did not promptly notify the pharmacy that the medication was unavailable.
Food storage and staff attire standards were not followed in the kitchen. Dry goods were found on the floor, dented cans remained on the active shelf for resident use, a refrigerator holding residents' drinks was above the required temp, and freezer items were uncovered and exposed to ice particles. The DM also prepared meal plates with his beard net below his mustache, despite knowing facial hair was supposed to be fully covered.
Unsanitary Kitchen Environment: The facility failed to keep the kitchen clean and sanitary. Surveyors observed grime on pantry and refrigerator doors, food crumbs in refrigerator seals, black grime on the ice machine, brown splatters on walls, grimy floors, soiled garbage cans, and splatters around the sink area. The DM stated he did not regularly monitor kitchen cleaning, and staff reported cleaning duties were assigned but not consistently completed.
A facility failed to maintain a safe, clean, comfortable, and homelike dining room environment. Surveyors observed dried red and brown splash marks on the walls near the dishwasher and exit doors, and the Housekeeping Supervisor said there was no cleaning schedule for the dining room and the walls had last been cleaned about a month earlier. The dining room light covers also had dark areas inside the lenses, and the DOR stated there was no formal schedule for cleaning the lights; one broken lens had been placed back up, leaving an opening where the bulb could be seen.
A resident with altered mental status and moderately impaired cognition fell from a bedside commode after a CNA turned her back to help the roommate with a blanket, despite the care plan requiring supervision while on the commode. The resident sustained a rib contusion, and the CNA stated the fall could have been prevented if she had not turned away or if another staff member had been present.
Unsafe and Unhomelike Resident Room Conditions: Surveyors observed stained, moisture-damaged ceiling tiles in several rooms and a supply closet, along with peeling paint and holes in resident rooms. A resident reported the room condition did not feel homelike, another said paint dust was getting onto belongings, and others said the holes made them feel unsafe or bothered them. The Maintenance Director linked the ceiling damage to a prior roof leak from clogged gutters, and the Administrator said repairs were usually handled promptly when reported.
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