Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A resident with post-stroke hemiplegia, chronic pain, COPD, and dependence on staff for transfers had an active physician order for a custom wheelchair to improve positioning and comfort, but the facility failed to follow through on obtaining it. The resident reported significant back pain from prolonged bedrest, could tolerate the current wheelchair for only brief periods due to discomfort, and largely remained in bed. The therapy director described completing evaluations and wheelchair forms and placing them in physician folders, but there was no documentation that the forms were processed or that a DME supplier completed the custom wheelchair order. The DON, social services director, business office manager, and administrator gave inconsistent accounts of who was responsible for ordering and tracking the wheelchair, and none had paperwork showing progress on the order. Despite a detailed DME policy and an order for a custom wheelchair, the facility did not ensure the resident received the ordered equipment or that staff reasonably accommodated the resident’s mobility and seating needs.
Failure to accommodate resident needs and preferences: A resident with COPD had an oxygen concentrator that repeatedly beeped and was not replaced despite the resident reporting poor sleep, frustration, and anxiety. In the dining room, a resident with dementia and weakness and another resident said the table was too high and made it hard to reach food, while a resident with dementia, DM, CKD, and COPD was observed with the call light on the floor out of reach despite needing staff help.
The facility failed to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment and Alzheimer’s disease, care planned to use the call light for assistance due to fall risk, was repeatedly observed in a recliner with the call light wrapped around the bed rail or under a pillow, out of reach, despite staff acknowledging the resident could use the call system and that it should be accessible. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure, dependent on staff for hygiene and care planned to have the call light within reach at all times, was observed in bed while the call light lay on the floor behind the headboard. In addition, a cognitively intact resident with arthritis and spinal stenosis, who used a wheelchair and lacked an in-room bathroom, reported that the 200 hall shower room had been unusable for over a month, forcing use of a more distant shower room; staff confirmed the shower had been broken for about a month and had not yet been repaired.
Two residents with cognitive impairment and toileting needs were denied access to their shared bathroom after staff removed the doorknobs, requiring them to rely on staff to access the main bathroom. Despite care plans and staff interviews lacking clear evidence of recent toilet clogging by these residents, both were left without independent bathroom access, leading to incontinence and use of inappropriate alternatives such as urinals and trash cans.
A resident with a recent below-the-knee amputation and vascular issues did not receive a physician-ordered wheelchair leg extender to keep the leg elevated. Despite multiple staff observations and care plan instructions, the resident was repeatedly seen with the amputated leg hanging down unsupported, and staff interviews revealed a lack of awareness and assessment for the required adaptive device.
A resident with multiple sclerosis experienced ongoing pain and discomfort due to the use of a manual wheelchair that was too small, which the resident had purchased independently. Despite reporting the issue to the DON and Social Services Director, and the facility's policy requiring accommodation of adaptive device needs, no timely occupational therapy evaluation or suitable replacement wheelchair was provided. Attempts to alleviate discomfort with a cushion were unsuccessful, and the resident continued to lack a properly fitting wheelchair.
Staff did not respond promptly to call lights for five residents who required assistance with toileting and transfers, resulting in episodes of incontinence and distress. Despite facility policy outlining call escalation procedures, call light logs showed repeated delays, with some calls unanswered for over 20 minutes. Residents and family members reported long wait times, and leadership was not fully aware of the extent of the delays.
Two residents with significant medical conditions and fall risks were repeatedly observed with their call lights out of reach, despite staff acknowledging responsibility for ensuring accessibility. One resident's call light was clipped to a privacy curtain, while another's was draped over a wall fixture, leaving both unable to summon assistance as needed.
The facility failed to accommodate the needs of two residents requiring power wheelchairs for independence. One resident, a paraplegic, was denied a power wheelchair despite having a physician's order and Medicaid approval, leaving them dependent on staff. Another resident with multiple sclerosis faced threats of having their motorized chair taken away, despite no documented safety concerns. The administrator's personal preference against motorized chairs led to these denials, contradicting the facility's policy on assistive devices.
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