The facility failed to maintain clean, odor-free, and safe carpeted rooms on one floor, as evidenced by strong urine odors concentrated around a specific room, visible dark stains, food debris, and a wet urine spot on the carpet near a bathroom door. Multiple staff, including LPNs, housekeeping, the DON, and maintenance, confirmed that a resident in that room frequently removed briefs and urinated on the carpet, and that urine odors were sometimes noticeable from the hallway. Additional observations showed that several other carpeted rooms had tears, deterioration, brown stains, and loose tiles creating tripping hazards. Staff reported that carpets were only cleaned when issues were reported verbally, and there was no routine or tracked schedule for deep cleaning or shampooing, despite a written policy requiring periodic deep cleaning of carpets.
Surveyors found that the facility failed to remove expired medications from a medication storage room and a medication cart, including expired ibuprofen, cranberry pills, lorazepam, and liquid acetaminophen, despite a policy requiring expired drugs to be returned to the pharmacy or destroyed. They also observed multiple instances where an LPN left medication carts unlocked and unattended while entering resident rooms to administer medications, with residents present near the carts, contrary to the facility’s policy that medication carts not be left unattended if open or accessible.
A resident with a history of wandering and elopement was moved from a room without a mesh gate to a room with a mesh gate on the door and was later observed yelling and unable to open the gate, which prevented exit from the room. A roommate reported that this resident often had difficulty opening the gate and called for help. The DON stated that residents who wander generally do not have mesh gates, that both roommates should be able to open any gate on their door, and that an assessment and care plan entry should exist for each resident using a mesh gate. The DON was unable to produce an assessment for this resident, confirmed the resident was not care planned for the mesh gate, and acknowledged that if an ambulatory resident cannot open a gate, it could be considered a restraint, contrary to the facility’s resident rights policy prohibiting restraints used for discipline or convenience.
Surveyors found that the facility failed to revise care plans after falls for two residents with multiple conditions including weakness, peripheral neuropathy, unsteadiness, Parkinsonism, heart disease, CHF, and mood disorders. In both cases, nursing notes documented falls related to weakness and self-transfer, and existing care plans already identified fall risk. However, the care plans had not been updated with new fall-prevention interventions following the incidents, despite an IDT meeting note stating that one care plan had been updated as needed. The DON confirmed that care plans are expected to be revised after each fall and that this did not occur for these residents.
A resident on comfort care with multiple chronic conditions received incorrect morphine doses when staff failed to verify that the concentration on the morphine bottle matched the physician’s order. The order specified Morphine 20 mg/5 ml with a 1 ml (4 mg) PRN dose, but the bottle was labeled Morphine 20 mg/1 ml. Nursing staff administered multiple 1 ml doses (20 mg each) and later 2.5 ml doses (50 mg each) from this higher-concentration bottle, contrary to the ordered doses. The DON, ADON, and Administrator confirmed that this occurred despite a facility policy requiring adherence to the 5 Rights of medication administration, including verifying that the medication concentration on the container matches the provider’s order.
The facility did not maintain clean air vents and related ceiling surfaces in three common dining areas, where 14 ceiling vents were observed with dark black, speckled, fuzzy residue covering about half to three-quarters of each vent, and multiple ceiling tiles showed brown water stains. The Maintenance Director confirmed the buildup on vents and stains, reported no records of vent cleaning and stated vents had not been cleaned during his four months in the role, while also noting dust on four sprinklers. Facility policy requires annual cleaning of vents and air handling units, and the Administrator acknowledged vents should also be cleaned when dusty. The IP confirmed the vents needed cleaning, and the DON reported that a significant number of residents had chronic respiratory diagnoses. Information from a NADCA-certified company cited by surveyors stated that dirty ducts can accumulate contaminants and, in settings with residents who have compromised respiratory status, can contribute to exacerbation of chronic respiratory illnesses.
The facility did not verify or document required competencies for a large number of contracted nursing staff, including licensed nurses and LNAs obtained through staffing agencies. Record review showed missing resident-care competencies for a contracted LNA, despite the facility assessment requiring skills such as wound management, dementia care training, behavioral interventions, infection prevention, safe lift/transfer, and emergency response preparedness. The DON reported that new and agency staff often did not receive facility training, that agency staff were only required to read policies through the agency system, and that competency was informally monitored after assignment rather than verified beforehand. A contracted LNA described starting work by going directly to the nurse’s station, receiving an assignment, and beginning work without task-specific orientation.
Two residents’ rights to privacy were not maintained during personal and incontinence care. In one instance, a resident received incontinence care from an LNA with the hall door open and the privacy curtain between beds not drawn, while a roommate and visiting family members were present and the resident remained visible. In another instance, a resident was exposed in bed while three LNAs provided personal care with the hall door wide open, and the door was only closed after staff noticed surveyors. The DON later confirmed that LNAs were expected to ensure privacy by using the curtain and/or closing the door.
A resident with several weeks of itching and self-inflicted scratches to the arms and hands was observed actively scratching with deep scratches present, while documentation showed repeated episodes of pruritus and open skin areas. Nursing staff had previously obtained a short course of Triamcinolone cream and later left messages for the physician requesting systemic medication (cetirizine) and reporting continued scratching and inflamed areas, but no new orders or documented physician response were received despite multiple calls and faxes. This resulted in the resident not being under timely physician supervision or receiving updated treatment in response to ongoing symptoms.
Surveyors found that physicians did not complete required total program of care reviews for two residents. One resident with multiple complex conditions, including dementia, cachexia, pressure ulcers, malnutrition, and dysphagia, had regulatory visit notes over an extended period that lacked documentation of a comprehensive care review, listed two medications that were not actually ordered, and failed to reflect documented MASD and pressure injuries noted in nursing progress notes. The DON confirmed the absence of a total care review and reported difficulty obtaining such documentation from some providers. Another resident admitted earlier in the year had no provider visit notes that met the definition of a total program of care review, including review of all current meds, treatments, and the comprehensive care plan.
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