A facility failed to maintain a clean, comfortable, and homelike environment when multiple hallways had scattered dry spots and scuff marks, a resident's room floor and fall mat had large dry tan substances, and the resident's mattress was discolored, foul-smelling, compressed, and had small bugs flying around it. Staff and leadership confirmed the conditions were not clean or sanitary, and the resident had cerebral palsy with severe cognitive impairment.
Failure to provide ordered wound care for three residents with wounds and pressure ulcers. One resident with a stage 3 ulcer and skin breakdown, one resident with a stage 2 pressure ulcer, and one resident with a skin tear abrasion all had MAR blanks showing missed treatments. LPNs confirmed the care was not completed, citing lack of wound care education, discomfort performing the treatments, uncertainty about responsibility, and high acuity on the hall. DONs confirmed that blank MAR entries meant the care was not done.
LPNs Assigned Wound Care Without Competency Assessment: Several LPNs were assigned wound care duties for residents even though the facility had not assessed their competencies or provided wound care training. The LPNs stated they had limited or no wound care education or certifications, and some said they did not feel comfortable performing wound care. Leadership confirmed wound care responsibilities had been shifted to floor nurses and that no competency evaluations or training had been provided.
A resident with a documented Amoxicillin allergy was given Amoxicillin-Pot Clavulanate via PEG by LPNs without first checking allergies or clarifying the order with the provider. The MAR showed multiple doses were administered, and nursing notes documented an itching reaction before the medication was discontinued and changed to Keflex.
Failure to complete annual CNA performance evaluation. The facility did not ensure that a CNA had a performance review at least once every 12 months. Review of the personnel file showed the CNA had a hire date in 2016 and no annual evaluation since the last one on file, and HR confirmed the evaluation was overdue and should have been done annually.
Delayed Incontinence Care: A resident who was cognitively intact and totally dependent for toileting was left in a soiled brief for hours despite pressing the call light and telling staff she needed to be changed. An LPN reported the resident’s increased bladder urgency was communicated to the assigned CNA, but the CNA forgot to return because she was busy with other residents; the resident was later found with a soiled brief and saturated bed sheets. The IDON stated CNAs were expected to round every 2 hours for incontinence care.
Improper utensils and dishware were used during meal service. Residents were initially given plastic utensils, and meals and desserts were served in Styrofoam containers with beverages in Styrofoam cups. Residents reported this happened often, with one noting the plastic utensils bent easily and another stating silverware was preferred. During lunch, most residents served meat were not given a knife and had to try to cut it with their hands or other utensils.
Ceiling tiles in multiple hallways were left discolored and damaged, with visible condensation, black substance, and mildew-like staining near an AC vent. In one resident room, an AC unit repeatedly leaked water into a basin and onto the floor, with exposed wall areas and stained, bulged bathroom paint; two cognitively intact residents reported the leak had persisted since admission and maintenance had not fully resolved it.
An incomplete allopurinol order was not clarified before administration to a resident. The order directed one tablet daily but did not include the dosage, yet nursing staff administered the medication for months, including 100 mg by mouth from the blister pack. An LPN stated the dose could not be verified and should have been clarified with the physician, who said he was not contacted about the missing dosage. The DON confirmed the order should have included a dosage and should not have been administered without clarification.
Missed Monthly Weights for Residents With Nutritional Concerns: The facility failed to obtain monthly weights for two residents with nutritional diagnoses and care plan monitoring needs. One resident had moderate protein-calorie malnutrition and a physician order for monthly weights, but the record showed a gap in weights with no documented refusal. Another resident with mild protein-calorie malnutrition and a care plan for altered nutritional status also had no monthly weight documented between recorded weights, and the DON confirmed both residents should have been weighed monthly.
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