Unsafe Resident Room Temperatures and Heat Injury: A resident with COPD, PVD, HTN, and moderate cognitive impairment was found in a very warm room with no fan or cooling device present and later had a temperature of 103.7°F after becoming confused and weak in the bathroom. Staff reported that room AC had not been working for weeks, the chiller needed recharging, and hydration passes were not increased despite hot weather. Other rooms were also warm, and staff confirmed they had not received education on recognizing or preventing heat injury.
Incomplete informed consent for psychotropic medications: The facility failed to ensure a resident or representative was fully informed before psychotropic meds were started or increased. Records for multiple residents showed consent forms that omitted dose, frequency, symptoms being treated, potential adverse effects, and alternative or non-pharmacological options for meds such as Alprazolam, Zoloft, Trazodone, Seroquel, Ativan, Cymbalta, Rexulti, Wellbutrin, Paroxetine, Lorazepam, Quetiapine, and Sertraline. The DON confirmed several consents were incomplete or missing.
Failure to Identify Causes and Individualize Fall Interventions: A resident with severe cognitive impairment, incontinence, and multiple psychoactive meds had repeated falls in the room and bathroom area. The facility often documented no causal factors or used limited interventions such as a reminder sign, med review, video monitoring, and alarms, while not addressing issues noted in the events such as toileting needs, feces in the bathroom, poor lighting, and refusal to wear gripper socks or shoes.
Incorrect Therapeutic Diet Served to a Resident with Dysphagia: A resident with pneumonitis, dementia, and dysphagia was ordered a minced and moist diet with mildly thick liquids, but was served regular chicken at lunch instead. The resident choked in the dining room, staff performed the Heimlich maneuver, and the resident was sent to the hospital after choking on a large piece of chicken.
A dietary service failure occurred when staff served residents portions that did not match approved recipe serving sizes. During meal service, aides used #16 2-oz scoops for rice, refried beans, and pureed taco items, resulting in servings that were only half of the required amount for rice and beans and far below the required portion for pureed tacos. In a satellite kitchen, staff reported using the required scoop, but only #12 and one #16 scoop were available, and an aide stated the same scoop was being used for all food items.
Kitchen staff failed to date and properly label multiple stored food items, including several expired products, and surveyors also observed improper hand hygiene and food handling practices. The DM was seen washing hands for too short a time, working with an empty soap dispenser, handling food with gloves and a knife in a way that raised cross-contamination concerns, and entering a bathroom while wearing a kitchen apron; facility policy required handwashing before and after glove use and food handling.
Staff failed to follow hand hygiene and glove practices while assisting residents with meals, including feeding more than one resident at a time, handling food and personal items, and not cleaning hands after removing gloves. Staff also allowed a resident’s urinary catheter drainage bag to remain on the floor and later on the resident’s lap while in the dining area. An LPN and other staff were observed assisting residents without consistent ABHS use between residents.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility administered psychotropic medications to multiple residents, including antidepressants and antipsychotics, without documented informed consent from the resident or representative. Records for residents with depression, dementia with agitation, and schizophrenia showed orders for medications such as mirtazapine, Paxil, Seroquel, duloxetine, risperidone, and Lexapro, but no evidence of advance discussion of risks, benefits, or alternative treatment options.
Failure to Notify Provider of Abnormal BP Readings The facility did not notify the provider when a resident’s BP was outside ordered parameters. One resident with HTN, stroke history, and repeated falls had many BP readings above the ordered limits over several months, with no documentation of provider notification. Two other residents with HTN also had BP readings below ordered limits, including low readings during med pass, and their records likewise showed no evidence that the provider was notified.
Hand hygiene was not performed during medication administration for multiple residents. An MA entered resident rooms, handled medications and resident items, donned and removed gloves without cleaning hands, and administered oral meds, creams, and eye drops without hand hygiene between residents. The MA confirmed hands were not being washed during med passes, and the Administrator stated staff frequently lacked readily available hand sanitizer at resident rooms.
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