Recent Survey Issues May – December, 2018

Recent Survey Issues May – December, 2018

Resident Council Meetings:

  • Residents not aware of Resident Council Meeting is held.

Weight Loss issues:

  • IDT not ruling out psychosocial issues related to weight loss when no clear medical cause indicated
  • Reason for weight loss not assessed at related to missing dentures

Request/Refuse/Treatment/Advanced Directives

  • Advanced Directives Acknowledgement form signed by resident/representative.
  • Resident missing an Advanced Directive

Environmental/Home-Like Environment:

  • BM smeared on toilet
  • No personalized items in long -term resident’s room (photos, artwork, etc)

Resident Rights/Person Centered Care/Dignity:

  • Call lights not answered in a timely manner
  • CNA refused to care for resident.
  • CNA overheard telling resident to come to her in order to provide care.
  • CNA did not inform RN that resident was in pain.
  • Photo of resident posted on social media
  • CNA calling adult brief – “resident’s diaper” in a negative manner
  • Eye drops being administered in dining room- dignity issue
  • Resident food preferences not followed
  • Resident served food that resident previously indicated she did not want
  • Resident found with maggots in foot wound


  • Hospice CPs not integrated with facility IDT.
  • 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 Base Line Care Plan within 48 hours of admission. Frequently cited.
  • No Comprehensive Care Plan with 15 days of admission.
  • Care Plan did not address resident’s anxiety and depression.
  • No signatures on Baseline Care Plan Meeting or Comprehensive CP meeting
  • Inadequate resident Care Plans- not addressing all required areas
  • 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


  • Grievance reports with no follow-up or resolution
  • Grievance reports not completed despite the grievance being addressed and resolved.

Theft and Loss:

  • SS staff not informed of missing items.
  • Response to f/u re: lost dentures not quick enough
  • Two discharged resident’s belongings mixed in with each others

Medically-related Social Service:

  • Res failed to receive requested podiatry services.
  • Lack of f/u or support visit following injury related to alleged abuse.

Behavior Management/Psychotropic Medications:

  • PRN Seroquel used beyond the 14 days allowed in new regulations. Cited several times.
  • No consent for psychotropic medication.
  • Behavior monitored does not match orders.
  • No GDR documented
  • No documentation of potential triggers prior to medication being prescribed


  • No Inventory in chart.
  • Glasses indicated on MDS not listed on Inventory
  • Inventory not closed out at discharge

Discharge Planning:

  • Home Health not referred despite MD order in chart.
  • 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”


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


  • No LCSW license on file.
  • Environment not home-like: no personal items and broken and torn screens in windows.
  • 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

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