Dirty Equipment, Vents, Ceilings, and Air Purifier: Surveyors observed mechanical lifts with dirt buildup, return air vents covered in dirt and dust, stained and damaged ceilings, and an air purifier covered in dirt and dried substance. In the dining area, a half wall and back wall had dried residue, and staff gave conflicting statements about who was responsible for cleaning the area and equipment. A lift in a resident room was also observed with dirt on the base and shaft.
A facility failed to report an alleged mistreatment during a resident’s hair grooming to the State Agency within the required timeframe. The resident had dementia, depression, severe cognitive impairment, and was dependent on staff for grooming and hygiene. Records showed a matted area of hair was removed, leaving a reddened scalp, and staff later described the event as an abuse allegation that should have been reported.
Failure to investigate alleged mistreatment during grooming: A resident with dementia, depression, and severe cognitive impairment was dependent on staff for grooming and hygiene. After a mat of hair was removed, the resident’s scalp was noted to be red and irritated, and staff later reported the resident was in pain after the hair was brushed out. The facility handled the issue as a grievance, but there was no documentation of a thorough abuse/mistreatment investigation, and the administrator later stated it should have been investigated as an abuse allegation.
Failure to Protect Resident from Verbal Abuse: An LPN yelled at a resident after the resident spit on a CNA, made scolding and threatening comments about jail, and was reported by multiple residents and staff as rude, mean, and verbally aggressive. Staff also reported the LPN said they were no longer in camera view and one witness stated the LPN slapped the resident's hand while yelling.
Failure to assign an infection preventionist. The facility’s infection preventionist resigned, and the administrator and DON stated that no one had been assigned or had accepted the duties of the position. The role remained unfilled, and no staff member had taken on the infection preventionist responsibilities.
Damaged and stained furniture in the memory care unit was observed during survey. Eight recliners had tears and cracks in the arms, and two couches in the dining area were stained, with one couch having a large slit exposing the cushion. An LPN and a CMA confirmed the furniture was worn and not in good condition.
Failure to Protect Residents from Sexual Abuse: A memory care resident with severe cognitive impairment, wandering, and behavioral issues was observed touching and kissing another resident inappropriately, including contact to the groin, chest, and face. A separate resident with dementia and moderate cognitive impairment reported the same resident entered their room at night and touched their breast/shoulder area. The DON stated resident behaviors were tracked daily, but there was no documentation of the behavioral findings or IDT tracking.
Failure to Report Abuse Allegation Within Required Timeframe: A resident reported that a CNA was too rough during care and did not want the CNA back in the room. The facility’s abuse policy required reporting abuse allegations to the state agency within 2 hours, but the DON stated the allegation was known at 7:50 PM and the initial report was not submitted until 10:06 PM. The resident had multiple psychiatric, cognitive, pain, and musculoskeletal diagnoses, and a BIMS score of 13 indicated intact cognition.
A facility failed to protect a resident from further potential abuse after the resident alleged that a CNA was rough during bed mobility and incontinence care. The CNA continued providing care to other residents until later that evening, despite the facility policy requiring immediate suspension of any staff member named in an abuse allegation; staff interviews confirmed the CNA was not removed right away and remained until the ADM and DON arrived.
Improper Transfer Assistance and Unsafe Hot Water Temperatures: A resident who required a mechanical lift and 2-person assist was transferred by 2 CNAs without the lift after staff did not check the care plan and relied on the resident's statements despite cognitive impairment; the resident was lowered to the knees and later diagnosed with a right femur fracture. Surveyors also found sink and shower water temperatures well above safe limits, with a resident reporting the water got hot immediately and maintenance noting multiple rooms exceeded regulation temperatures.
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Citations used to create this checklist
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