Gables of Green

Based on observation, medical record review, and interview the facility failed to administer medication per prescriber's order. This affected one (Resident #2) of four residents observed for medication administration. The facility census was 93.

Findings include:

Record review revealed Resident #2, who had a diagnoses of congestive heart failure, had an order for Lasix 40 milligrams (mg) (a diuretic medication) to be given once daily in the morning. Resident #2 also had an order for two tablets of Potassium Chloride 20 milliequivalents (mEq) (electrolyte supplement) to be given every day upon rising.

During observation of medication administration on 12/05/22 at 10:20 A.M., with Licensed Practical Nurse (LPN) #3, Resident #2 was observed receiving Lasix 20 mg, and one tablet of Potassium Chloride 20 mEq.

During interview with LPN #3 on 12/05/22 at 12:45 P.M., it was verified that Resident #2 was given Lasix 20 mg and one tablet of Potassium 20 mEq and that the order was for Lasix 40 mg and two tablets of Potassium 20 mEq.

Based on observation, dietary spreadsheet review, and interview the facility failed to provide the correct food serving sizes to ensure nutritional adequacy. This affected all 23 residents (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25) residing on the memory care unit. The census was 93.

Findings include:

Review of the diet spreadsheet for Week One of the fall/winter menu revealed two #8 dips (four-ounce) was to be used to serve the beef and noodles and a #8 dip (four-ounce) was to be used to serve the pureed lemon baked food and mashed potatoes.

Observation on 12/05/22 at 12:10 P.M. revealed Cook #2 was serving food from the steamtable in the kitchenette on the memory care unit. Cook #2 was using a three-ounce spoodle to serve two portions of the beef and noodles. Cook #2 was using non-measured spoodles to serve the pureed fish, mashed potatoes, and pureed corn. Interview, during the observation, with Cook #2 verified the incorrect serving size was used to serve the beef and noodles and verified non-measured serving spoodles were used to serve the pureed fish, mashed potatoes, and corn.

Based on observation, interview, and policy review the facility failed to ensure food was stored, prepared, and served in sanitary manner. This affected all residents residing in the facility. The census was 93.

Findings include:

An initial tour of the kitchen and kitchenette's on 12/05/22 at 9:45 A.M. with Dietary Manger (DM) #2 revealed there weren't any food temperatures recorded for breakfast, lunch, or dinner on 12/04/22. Cook #3 was not wearing a hair net while standing by the stove, preparing food in the kitchen. There was an 18-quart container of a yellow, liquid substance and six-liter container of shredded cheese without a label or date in the walk-in refrigerator in the kitchen. There was a gallon of milk with a sell by date of 11/30/22 in the reach-in refrigerator in the assisted living kitchenette; there was not an open date labeled on the milk. There was a gallon of milk with a sell by date of 11/30/22 in the reach-in refrigerator in the memory care unit; there was not an open date labeled on the milk. Interview, during the observation, with DM #2 verified the findings.

Observation on 12/05/22 at 11:05 A.M. revealed Cook #3 taking lunch food temperatures in the kitchen. Cook #3 would take the temperature of a food, use an alcohol pad to clean the thermometer, wipe the thermometer with a rag hanging out of a sanitation bucket then proceed to insert the thermometer into another food on the steam table. DM #2 checked the parts per million (PPM) range of the sanitizer and the test strip turned yellow which did not register on the test strip color range. Interview, during the observation, with DM #2 verified the yellow color on the test strip did not register in the test strip range. DM #2 was not aware of the appropriate sanitizer PPM range.

Observation on 12/05/22 at 12:10 P.M. revealed Cook #2 was not wearing a hair net nor a beard cover while serving food from the steamtable in the kitchenette on the memory care unit.

Interview on 12/05/22 at 12:20 P.M. with Executive Director #4 verified Cook #2 should have been wearing a hair net and beard cover while serving food to cover his hair and beard.

Review of the facility's food temperature audit policy, dated 2018, revealed the temperatures of the food are documented on the food temperature audit form.

Based on observation, medical record review, and interview the facility failed to provide a safe environment and adequate supervision to prevent an elopement for Resident #1. This affected one (Resident #1) of three residents reviewed for elopement. The census was 93.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 03/02/18 with diagnoses of personality and behavioral disorders and Alzheimer's disease. Resident #1 resided on the memory care unit.

Review of the elopement risk screening assessment, dated 05/20/21, revealed Resident #1 was at risk for elopement.

Review of the incident note, dated 07/09/21, timed 3:41 P.M., authored by Licensed Practical Nurse (LPN) #5, revealed Resident #1 observed walking behind [name of nearby grocery store] by fellow resident's family member and was escorted back to facility by said family member via personal vehicle. Resident #1 was last seen in the memory care unit after returning from music even held in assisted living right before dinner. Upon return from said event, Resident #1 had been redirected by staff to go to the dining room for dinner because she was attempting to intervene with roommate's care/toileting. Resident #1 then stated they were going to go for a walk. Resident #1 routinely ambulated throughout the unit daily. Upon return from said elopement, Resident #1's window screen was observed lying on the bed and the window was open. The plastic clip to keep the window closed was hidden in the resident's drawer. A functioning wanderguard (triggers alarms and can lock monitored doors to prevent resident leaving unattended) was reapplied to the resident's right ankle, notified maintenance, Power of Attorney (POA), and physician of occurrence. Will reenforce safety checks hourly and will educate staff for patient safety.

Review of the behavior note dated 07/18/22, timed 7:30 A.M. revealed as off going nurse was leaving the unit out the main exit doors, Resident #1 immediately followed the nurse off the unit, no alarms sounded as the nurse had entered code to exit unit. This nurse heard the door close and looked up to no longer see Resident #1 and immediately/exited nurses' station and approached exit door to see off going nursing returning to unit escorting Resident #1. Safety checks continue every half an hour. The physician and POA were notified.

Review of the incident note dated 11/27/22, timed 2:35 P.M. revealed Resident #1 was observed by the main dining room server sitting in the seating area. The server got the nurse. The nurse and one care partner assisted Resident #1 back to the memory care unit. Resident #1 was resistant at first to go back to unit stating she can't go in because there was a man over there who had zeroed in on her, got her up against wall and kissed her. The nurse and care partner assured the resident that they were dealing with the man and will keep a close eye on her to protect her. Resident #1 then walked back onto the unit and ate lunch but was still very paranoid. Resident #1's wanderguard was not setting off the alarm when passing through the doorway. The nurse tested the wanderguard and no alarms sounded. The nurse attempted to activate a new wanderguard with no success. Assistant Director of Nursing (ADON) was to come in to activate the wanderguard. Until then, visual checks were being completed and charted on paper.

Review of the physician orders from December 2022 revealed to check Resident #1's wanderguard placement on her right ankle. The physician orders did not indicate to check the function of the wanderguard.

Observation on 12/05/22 at 10:40 A.M. revealed Resident #1 was sitting a dining room chair, participating in an exercise activity in the common area of the memory care unit. Resident #1 had a wanderguard on her right ankle. Resident #1's bedroom window had a plastic barrier affixed to the side to prevent the window from raising.

Interview on 12/05/22 at 11:55 A.M. with LPN #5 revealed on the day of Resident #1's elopement, Resident #1 had been on the assisted living side of the building for a music activity from approximately 2:30 P.M. to 3:00 P.M. After the music activity ended, a care partner brought Resident #1 back onto the memory care unit. Resident #1 had become fixated on another resident and a care partner had to redirect her. Resident #1 had become upset and started walking/pacing around the memory care unit. The next thing she knew, the receptionist was returning Resident #1 to the memory care unit. Former Resident #26's daughter found Resident #1 around 4:00 P.M.

Interview on 12/05/22 at 12:15 P.M. with LPN #7 revealed Resident #1 continued to be exit seeking and the nurses were not checking Resident #1's wanderguard to ensure function.

Interview on 12/05/22 at 2:50 P.M. with the Director of Nursing verified the facility was not checking the function of Resident #1's wanderguard.