Failure to Supervise a Resident with Dementia and Wandering Behaviors: A resident with severe cognitive impairment, high wandering risk, and repeated falls did not have an individualized person-centered behavior plan for wandering or exit-seeking. Video showed the resident moving around the unit, attempting to follow visitors out an exit, entering another resident’s room, and remaining there undetected for about 44 minutes before being found crawling out with forehead bleeding. EMS transported the resident to the hospital, where the bleeding was documented as reinjury of prior sutured lacerations.
Failure to Maintain Resident Dignity During Meal Service: During lunch meal service, meals were served on trays with plates and utensils left on the trays for all observed residents, and one resident who required set up and supervision with eating waited more than 20 minutes while others at the same table received and finished their meals. The resident, who had diagnoses including depression, mild cognitive impairment, anxiety, tremor, malnutrition, and muscle weakness, stated that waiting to be served made him feel left out; the DON confirmed the dignity concern.
Kitchen and equipment were found dirty and unsanitary, including a food processor, electric can opener, toaster, drawer, cutlery tray, reach-in freezer, hanging light fixtures, and HVAC vents/grills with visible debris and crusted buildup. The CNA, CDM, and MD all confirmed the items and surfaces were not clean and sanitary.
Failure to Timely Report Allegations of Resident-to-Resident Abuse: The facility did not report allegations of potential resident-to-resident abuse within the required timeframe for two separate incidents involving four residents. One report was sent 18 hours after the event, and another was not reported until 5 days later, despite the DON confirming the reports were not made within 2 hours of the facility becoming aware of the allegations.
Failure to Revise Care Plans for Skin Changes: The facility did not revise the comprehensive care plans for two residents to reflect changes in skin integrity. One resident had a stage 2 pressure ulcer with physician orders for zinc oxide and heel floating, while the other had scabbed areas, scratches, self-inflicted abrasions, and shearing to the buttocks with related orders for lotion, protective sleeves, and barrier cream. The RN MDS Coordinator confirmed the care plans were not updated to include these skin-related problems and treatments.
A resident with CHF, CKD, and cardiomyopathy, and severe cognitive impairment, was observed receiving oxygen at 3 L/min by nasal cannula without a physician order. The chart showed no oxygen order during the review period, and an LPN confirmed the omission before an order was later obtained.
A resident with an indwelling catheter and moderate cognitive impairment had a foley drainage bag left uncovered and visible to anyone entering the room. The resident had an order for a privacy cover every shift, but repeated observations showed no cover in place, and an LPN confirmed the cover was missing. The DON stated the expectation was that all foley drainage bags would have privacy covers to maintain resident dignity.
PASRR screening was inaccurate for two residents when Level 1 PASRRs stated no mental health diagnosis was known or suspected, despite the medical record and MDS showing active mental health diagnoses. One resident had Alzheimer’s Disease with Anxiety Disorder and severe cognitive impairment, and another had Dementia with Psychotic Disturbance, Insomnia, and Adjustment Disorder with Anxiety, also with severe cognitive impairment. The DON confirmed the PASRRs did not reflect the residents’ current diagnoses.
Failure to Offer Hand Hygiene During Meal Service: A CNA delivered meal trays to three residents, set up each meal, and did not offer hand hygiene before the meal service. The residents had diagnoses including muscle weakness, dysphagia, malnutrition, hypotension, diabetes, and anxiety, and each required staff assistance with meal setup; two were cognitively intact and one had moderate cognitive impairment. The CNA confirmed the omission, and the DON stated hand hygiene was to be offered prior to meals.
Food items in the kitchen were found stored without required labels, use-by dates, expiration dates, or stock dates. Surveyors observed unlabeled and undated items in the walk-in refrigerator, freezer, and dry storage, including scrambled egg mixture, watermelon halves, chicken breast, spinach, tater tots, chicken nuggets, fish strips, pork loins, rice, flour, ravioli, soup, and other items. The CDM confirmed several items lacked proper dating and acknowledged some dates were incorrect or missing.
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