A resident with impaired mobility, incontinence, CKD, and venous insufficiency developed a facility-acquired unstageable sacral PU that progressed from a blanchable red area to a worsening wound with slough, eschar, drainage, odor, pain, and infection. Staff notes showed the wound deteriorated over time, yet the resident was removed from provider rounds and did not receive a provider evaluation for 27 days while the ulcer enlarged and later merged with a new stage 2 area. The PA stated she expected staff to arrange provider review for a significant decline, and a nurse agreed the resident should have been seen sooner.
Dishwashers in the main kitchen and on the Edgewater unit failed to reach the required 160°F rinse temperature needed to sanitize dishware. Surveyors observed temperatures below standard using an irreversible registering thermometer and a color-indicator test strip, and facility staff confirmed the rinse cycle did not meet requirements.
A resident with ESRD on hemodialysis, CHF, DM, and depression experienced significant weight loss while the facility failed to document multiple post-dialysis weights, complete a comprehensive dietary assessment, or implement nutritional interventions. Staff confirmed the resident frequently refused meals after dialysis, and the EHR lacked several weights needed for nutritional monitoring despite a physician order to compare dry post-dialysis weights.
Failure to prevent repeated resident-to-resident physical abuse occurred when a resident with Alzheimer’s disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering was involved in multiple altercations with peers. The resident’s care plan documented agitation, physical aggression, verbal aggression, wandering into peers’ rooms, and taking items, and progress notes showed incidents of grabbing, kicking, flicking, hitting, choking, and punching other residents, as well as being struck by peers during these events. Admin staff said behaviors were discussed daily, but the facility did not effectively manage the resident’s behaviors, resulting in repeated abuse episodes.
Emergency suction machines were not kept ready for use on 4 of 4 resident care units. Staff found machines boxed, unassembled, or difficult to locate in the clean utility room, and one nurse stated the last time she tried to use a suction machine, it did not work. An RN and other staff confirmed that unpacking or locating the equipment would delay response during an emergency.
Housekeeping and environmental cleanliness were not maintained consistently in resident rooms and common areas. Surveyors observed dust, food crumbs, debris, sticky and wet floors, odors, unemptied trash, and soiled briefs left on a wheelchair and scooter seat. Residents and a family member reported that bathrooms and trash were not being cleaned or emptied regularly, and an admin staff member stated staff were expected to clean rooms as needed and remove trash to the soiled utility room.
The facility failed to keep several resident care plans current with changing needs and treatments. A resident with wounds and a fluid restriction had outdated wound, infection, and fluid details in the care plan; another resident's skin treatment order changed from Triad to Calmoseptine but the care plan was not updated; one resident's diuretic therapy was not reflected; another resident's care plan missed current incontinence and toileting needs; one resident's care plan still listed a pressure ulcer when no open areas were present; and another resident's mobility and transfer status did not match observed care, including a two-person pivot transfer instead of ambulation with a FWW.
The facility failed to keep the main laundry room free of hazards for 2 of 2 dryers. Surveyors observed lint buildup on the back of the dryers, including the top, openings, gas lines, and inside the machine openings, with gas dryer flames visible through the openings. Laundry staff stated no one cleans behind the dryers and that they only clean the floor and what they can reach.
Insufficient nursing staffing led to delayed call light response and missed or delayed care for multiple residents. A resident’s family reported long waits for assistance and a ventilator issue, another resident missed showers because there were not enough staff to provide two-person care, and other residents reported long delays for bathing, linen changes, and toileting. Call light reports showed waits up to 45 minutes, and staff confirmed the unit was short-staffed with only one CNA for 33 residents during part of a shift.
Staff failed to follow infection control precautions during resident care, including improper glove changes, missed hand hygiene, and failure to use required PPE and EBP. During toileting, transfers, and other hands-on care, CNAs removed and reapplied gloves without hand hygiene, touched their own face while gloved, and handled equipment and room items without cleaning their hands. Other residents with C. difficile, chronic wounds, or indwelling devices did not have required EBP or TBP measures in place, and staff entered rooms without the required gown, gloves, mask, or soap-and-water handwashing.
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