Failure to Notify Residents of Room Changes: The facility did not complete room change notifications for two residents whose rooms were changed, and no documentation of notice was found in the medical record. One resident with BIMS 15 said she was okay with the move but did not know until the day of the change. An LSW confirmed the notifications were not completed and could not show the resident was aware of the room change.
Failure to timely notify a resident’s MPOA of a hospital transfer related to a change in condition. The DON confirmed the resident was transferred to the hospital, but the MPOA was not notified at the time of transfer and was not documented as notified until an email was sent later. The DON acknowledged the delay was not consistent with facility expectations or federal requirements.
Failure to provide timely incontinent care: A cognitively intact resident was found in urine-soaked clothing and linens with a strong urine odor in the room. Although an NA documented care and later stated she had not actually changed the resident, the resident remained unchanged even after the DON directed staff to provide care, and the resident was tearful when she said she still had not been changed.
Staff incorrectly told resident representatives that transfers to a higher level of care would be treated as AMA discharges and that the residents could not return. One resident with a UTI, IV therapy, refusal of care, and repeated IV removal was sent to the hospital after the family requested transfer, and another resident was transferred for behavioral issues after the family had asked for acute care. In both cases, staff communications to the family and hospital incorrectly labeled the transfers as AMA.
The facility failed to timely notify the Ombudsman of resident transfers and discharges. Record review showed multiple months in which notices were not sent, and for one resident transferred to the hospital, the Ombudsman notification was delayed until months later. The DON confirmed the late notification and stated an action plan was in place.
A resident with osteomyelitis of the toes of the R foot was admitted with an identified need for wound care, but the facility did not obtain wound care orders or start treatment until several days after admission. The record also showed prescribed meds were not ensured to be available and administered as ordered, and there was no documentation of interim wound care, protective measures, or physician notification about the delay.
Infection Control Deficiency in Urinal and Linen Storage: The facility failed to maintain infection control practices when used urinals containing urine were left on over-the-bed tables for multiple residents without documented resident preference, and soiled, damp linen was found stored in the shower room on the shower chair, in the bathtub, and on a mechanical lift. The DON and Corporate Nurse confirmed the urinals and linen were not being stored as required by facility policy.
Ineffective pest control allowed gnats to be seen in a resident’s room and throughout common areas, including the dining area, nurses station, and conference room. The resident complained about gnats in the room, and the Administrator, DON, and Corporate Nurse stated the issue may have been related to recent roof repairs.
Inadequate supervision and poorly documented behavior interventions allowed a resident with repeated agitation, wandering, and room-entry behaviors to enter another resident’s room and engage in a struggle over an iPad. The other resident fell and sustained a subarachnoid hemorrhage and subdural hematoma. Staff and the DON reported that redirection was often ineffective, behavior monitoring was not in place, and the care plan had not been meaningfully updated to address resident-to-resident behaviors.
Meal service did not follow posted menus and tray cards for several residents. A resident did not receive milk, two residents did not receive poultry gravy, one resident on a pureed diet was served a regular roll instead of the ordered item, and another resident’s cereal tray was missing a serving and milk. An LPN, nurse aide, and account manager confirmed the missing or incorrect items during the dining observation.
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