The facility failed to ensure RN coverage for at least 8 consecutive hours on 3 of 46 days reviewed. Review of the Direct Care Staff Daily Reports showed no required RN coverage on three dates, and the Administrator acknowledged the missing coverage.
Ice Machine Drain Lacked Required Air Gap The facility failed to ensure the dual ice and water machine had the required air gap. A flexible drain line was observed entering the kitchen through a wall opening and resting in contact with the kitchen drain, with part of the hose coiled in the drain and discolored with splotchy pink areas. The Maintenance Director confirmed the drain line setup, and staff acknowledged there was no air gap present.
Failure to Follow Contact Precautions: Two residents were on contact precautions, including one with an MDRO UTI and another with C. diff. Staff did not consistently follow posted PPE and hand hygiene instructions, including a CNA entering a room without gown and gloves and CNAs using hand sanitizer instead of soap and water when leaving a resident’s room.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident with depression and delusional disorders was prescribed Olanzapine for delusions, but the MAR and care plan showed no targeted behavior monitoring or other behavioral documentation to support the medication’s use or effectiveness. The SS Director and DNS both confirmed the resident was not on behavior monitoring, despite the facility stating residents on antipsychotics were placed on it.
A resident with idiopathic aseptic necrosis of the right femur and ongoing hip pain had a PRN oxycodone order every 4 hours, but the medication was delayed after the resident and CNAs reported the need for pain relief. The LPN stated the dose was not yet due and later said the resident was asleep, while the DNS said the delay occurred after an early morning fire drill and resulted in the resident going 7 hours without PRN pain medication when it could have been given every 4 hours.
A former RN failed to follow professional nursing standards when she gave a resident edible marijuana that was not ordered by the physician. An LPN observed the RN cut up what appeared to be candy in the resident’s room, then identify it as marijuana gummies and place pieces within the resident’s reach. The resident had osteoarthritis, mild cognitive impairment, anxiety disorder, and PRN pain orders including tramadol, acetaminophen, heat or ice, and morphine.
A resident with dementia-related cognitive impairment and PRN pain medication orders was given edible marijuana by a former RN without a physician order. Another staff member observed the former RN cutting what appeared to be marijuana gummies into smaller pieces and placing them within the resident's reach, and the resident was later monitored after the incident.
A resident with moderate cognitive impairment and an identified elopement risk wandered, became agitated, and stated a desire to leave the facility. Staff attempted redirection, but the resident exited through an improperly latching perimeter door and was found about one block away on a main road after being missing for about 10 minutes. Observations also showed staff passing through the back fence gate without entering a code, and the maintenance director acknowledged the gate was not always locked.
A facility failed to maintain a homelike dining environment when tablecloths were removed from the dining room tables. Resident council minutes showed residents preferred the tablecloths, but dietary staff said labor cuts eliminated linens and they did not expect them to return. Observations during mealtimes showed no tablecloths on any table, and residents stated the dining room was more inviting with tablecloths and that budget reasons were given for not having them. Leadership acknowledged the dining room was not a homelike environment.
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