Unsanitary conditions were observed in the walk-in cooler, walk-in freezer, and dry storage area. The cooler had debris on the floor, a dark brownish/grayish/blackish substance on the wall, shelving, and food containers, and water leaking from the ceiling fan due to condensation. The freezer had food debris and ice buildup on the floor and door threshold, and the dry storage area had fallen crackers, crumbs, and other debris. The Dietary Manager reported ongoing leaking and cleaning issues, while Maintenance and dietary leadership described inconsistent communication about the concerns.
MDS assessments were inaccurately coded for multiple residents in areas including ROM, dental status, PASRR, physical restraints, and active diagnoses. One resident with hemiplegia, hemiparesis, and contractures had a bed rail coded as a restraint instead of an enabler and did not have upper extremity impairment reflected; another resident who was edentulous was coded as having no dental issues; a resident with a Level II PASRR was coded incorrectly; another resident’s half-side rails were coded as restraints; and a resident with psychiatric diagnoses had schizophrenia omitted from the MDS.
Failure to obtain psychotropic medication consent before initiation or continuation of ordered meds affected three residents. One resident with anxiety and depression received buspirone and escitalopram, another resident with anxiety/depression received mirtazapine, and a third resident with major depression received sertraline; in each case, the MAR showed the meds were given as ordered, but the record lacked documentation that the resident or representative was informed in advance of the risks and benefits. The DON, Psychiatric NP, Medical Director, and Administrator stated consent was required for psychotropic meds, including when residents were admitted on them or when doses were increased.
Incomplete Abuse Investigation and Reporting: A cognitively intact resident reported that a nurse aide grabbed her and yanked off her gown, leaving bruising on her arms. The DON and nursing staff documented the allegation and substantiated abuse, but the investigation was limited to one hall and did not include a resident statement, a statement from the accused aide, or broader interviews and skin checks. The facility notified DHSR and law enforcement, but APS/DSS notification was not documented.
Failure to complete a comprehensive trauma screening assessment on admission for a resident with anxiety disorder and insomnia. The resident and RP reported a history of domestic violence, but the chart had no trauma screening or trauma-informed care plan. The DON said the trauma history was unknown because the assessment was never completed, and the Medical Director and former SW stated that trauma screening was not being done for new admissions.
Expired medications were found on the 100 Hall med cart during an observation with an RN present, including benzonatate, metoclopramide, and ondansetron past their expiration dates. The RN stated she was a PRN employee on her second shift and had only checked meds she administered, not the full cart. The Unit Coordinator and DON stated staff were instructed to inspect med carts routinely, and the DON said weekly and monthly inspections had been completed, including a pharmacy inspection that did not note expired meds.
Failure to Maintain Dryer Lint Traps: Surveyors observed heavy lint buildup in both dryer lint traps, with lint hanging from each trap and covering the full trap surface. The sign-off log showed no entries after the prior shift, and staff interviews confirmed the required two-hour checks and documentation were not consistently completed.
Late Completion of Annual MDS Assessment: A resident's annual MDS assessment was completed after the required timeframe. The MDS Coordinator said she became overwhelmed by multiple new admissions, and the Regional MDS Consultant confirmed the assessment was late after the facility identified coding and completion issues through a scrubber report. The Administrator stated MDS assessments were expected to be completed and submitted within regulatory timeframes.
A resident with severe cognitive impairment, COPD, chronic respiratory failure, and seizure disorder did not receive showers as scheduled despite being dependent on staff for bathing. NA documentation showed multiple scheduled showers were marked not attempted and/or refused, while available shower sheets were incomplete. During observation, the resident appeared unkempt and said she was supposed to get two showers a week but had gone more than three weeks without one.
A resident with Barrett's Esophagus, DM2, and COPD did not receive a timely referral for routine endoscopy and colonoscopy as ordered by the prior NP. The resident said she assumed the appointment was being arranged, but the referral was not completed until much later, and the current NP, Scheduler, DON, and Administrator all described a breakdown in communication and order follow-through.
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