Recent Survey Issues November to May 2019

Downloadable Version

Resident Council Meetings:

  • Residents not aware of Resident Council Meeting is held.
  • Complaints in Resident Council not addressed

Weight Loss issues:

  • Reason for weight loss not assessed as related to missing dentures
  • Advanced dementia not indicated as related to weight loss

Request/Refuse/Treatment/Advanced Directives:

  • Resident missing an Advanced Directive
  • MD not talking to resident when completing POLST
  • No SS documentation of speaking to resident/representative about completing an AD

Environmental/Home-Like Environment:

  • No personalized items in long -term resident’s room (photos, artwork, etc)
  • Torn bed curtain

Resident Rights/Person Centered Care/Dignity:

  • Photo of resident posted on social media
  • CNA calling adult brief – “resident’s diaper” in a negative manner
  • Resident served food that resident previously indicated she did not want
  • No communication board on wheelchair
  • No communication board in room


  • No CP re: end of life care
  • Hospice staff name and phone number not on resident’s chart for easy access
  • Lack of IDT communication with hospice agency

Care Planning:

  • No Comprehensive Care Plan with 15 days of admission.
  • Care Plans not updated as resident condition changed
  • Comprehensive Care Plan did not adequately address resident’s foot wound and maggots
  • No Comprehensive Care Plan until day 41 of admission
  • Care Plans not individualized- computer generated without individualizing
  • Problems & interventions realistic?
  • Missing care plan for non-English speaking residents


  • Grievance reports with no follow-up or resolution
  • Grievance reports not completed despite the grievance being addressed and resolved
  • SSD not informed of resident grievance

Theft and Loss:

  • Two discharged resident’s belongings mixed in with each other’s
  • Lack of documentation that resident/representative was satisfied with resolution
  • Lack of documenting that resident was informed, in writing, the risk of keeping cash at bedside

Medically-related Social Service:

  • Resident failed to receive requested podiatry services.
  • Lack of followup or support visit following injury related to alleged abuse.
  • SSD asked by Surveyors if she had a “script of questions” when investigating abuse complaints

Behavior Management/Psychotropic Medications:

  • Behavior monitored does not match orders.
  • No GDR documented
  • No documentation of potential triggers prior to medication being prescribed
  • Behaviors related to psychiatric diagnosis or symptoms of dementia?
  • Justifications for GDRs and no GDRs
  • GDR, no individualized reason for no dose reduction


  • No Inventory in chart- frequently cited
  • Glasses indicated on MDS not listed on Inventory
  • Inventory not closed out at discharge
  • Items in resident’s room not on Inventory.
  • Inventory lacking 2 signatures

Discharge Planning:

  • Notice of transfer/discharge not faxed when resident was admitted to hospital- cited frequently
  • Lack of SS discharge planning notes- need to demonstrate “sufficient preparation for d/c”
  • Ombudsman not informed of resident discharge


  • POLST indicates No DNR, no order chart.
  • MD orders say “follow the POLST”- POLST was not signed by MD.
  • No MD signature on POLST
  • MD section incomplete


  • Comprehensive Care Plan not reviewed with resident/representative
  • No P & P for vision services, including monitoring appointments
  • Residents not aware of where Survey Results are posted
  • Resident’s personal food in refrigerator not dated
  • Quality Assurance program did not address repeated issues regarding inadequate wound care
  • Review of closed charts from 2016 and 2017
  • Requested copy of Room Change P & P
  • Request for recent SS Consultant Report
  • Request copy of Consultant SW License
  • Surveyors came in on a complaint, then asked to see charts of two discharged residents
  • Face Sheets needs to list alternate MD by name
  • Review for Bed Hold Notices in closed charts

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