Two residents receiving insulin did not have ordered blood glucose checks completed, including missed checks when one resident was sleeping and a documented shortage of test strips. One resident with type 2 DM had multiple missed BG checks and no documentation that the provider was contacted when BG exceeded the ordered threshold, while another resident with type 2 DM, CHF, chronic respiratory failure, and obesity also had missed q4h BG checks and no provider notification documented for BG readings over 400 mg/dL.
Sewage flooded the second-floor hallway, resident rooms, and bathrooms, with wastewater also leaking into a first-floor office. Video and interviews showed staff laying towels and sheets across the corridor to soak up the sewage while confused residents and wheelchair users moved through the contaminated water, and one resident reported sewage backing up from toilets and shower drains with urine and feces in the water.
Failure to maintain the sewer line and sanitary environment resulted in raw sewage backing up through toilets and shower drains into resident rooms and hallways, with wastewater also leaking into an office area. Residents reported repeated clogs, the building water supply was shut off for hours, and staff confirmed corroded piping, flushed wipes, and that no medical or clinical assessments were completed after residents were exposed to sewage and fumes.
A resident with type 2 DM, CHF, chronic respiratory failure, and obesity did not receive a prescribed daily Tradjenta 5 mg dose as ordered. The MAR documented the medication was out of stock on one occasion and not in stock on another, while the DON stated the pharmacy had received the prescription and the medication should have been available for administration; staff also described standard processes for reordering and obtaining medications when supply is low or unavailable.
Failure to supervise a resident at risk for elopement: A resident with hemiplegia, altered mental status, and schizophrenia was assessed as unsafe to leave unsupervised due to exit-seeking behavior, poor compliance with safety instructions, and lack of awareness of safety concerns. Staff later found the resident outside the facility after a CNA saw her on the sidewalk, and records show she eloped, was located hours later, returned refusing assessment, and was sent for an emergency involuntary psych commitment.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Elopement Prevention and Supervision Failure: Two residents with documented wandering and elopement risk left the facility unsupervised. One resident with Parkinson’s disease, cognitive impairment, and repeated exit-seeking behavior exited through a door that did not latch properly and was later found walking on a high-traffic street. Another resident with dementia and Alzheimer’s disease was reported to have followed visitors out and was later found outside the building despite a wander guard and care plan interventions.
A resident with lymphocytic leukemia on hospice had newly ordered comfort medications for pain and anxiety that were not promptly entered or administered. The nurse received hospice orders, but interpreted a later set as replacing the earlier scheduled orders, and the MAR showed missed doses of morphine and lorazepam over a two-day period.
A resident who was dependent on staff for bed mobility and repositioning fell out of bed during a bed bath while one staff member was providing care. The resident had encephalopathy, chronic respiratory failure with hypercapnia, and severe obesity, and the care plan and MDS showed the resident required total assistance for bed mobility. The resident slipped off the edge of the bed, landed on the floor, and was later sent for hospital evaluation after complaints of pain and concern for possible head trauma.
Failure to Maintain Safe Environment and Provide Adequate Supervision: Two residents with dementia-related conditions and recurrent falls were not consistently protected from hazards or adequately supervised. One resident had repeated falls from a wheelchair or bed area with reused or nonpreventive interventions, while another resident wandered the locked unit, entered other residents’ rooms, attempted to exit, and was observed without staff present in the hallways or at the nurse’s station.
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