Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
Summary
The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall. This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured. The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.
Removal Plan
- Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
- Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
- Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
- A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
- The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
- The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
- The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
- An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
- Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
- All residents were identified as potentially affected by the deficient practice.
- The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
- A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
- Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
- Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
A resident with a history of substance use, recent toe amputations, bilateral lower extremity impairment, a PICC line for IV antibiotics, and intact cognition signed a consent for a substance use safety program that included restrictions on LOA and required supervision, but the program was never implemented and no additional supervision was added. Despite staff awareness that the resident was focused on retrieving a motorized wheelchair and likely to leave, the resident accessed the LOA book, signed out without verbally notifying staff, and left with a friend to get the chair. Facility leadership had previously told the resident he could get the chair if he found a way, and when staff learned he was riding the wheelchair back several miles, they did not arrange transportation, instead considering him on LOA because he was alert and oriented. The resident traveled through the community, including stops at private homes, businesses, and a tavern, before returning later that evening, and the deficiency was cited for failure to keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with multiple medical conditions, including COPD and chronic respiratory failure requiring O2 via nasal cannula, was care planned as at risk for injury related to smoking, with interventions requiring supervision during smoking and storage of all smoking items at the nurse station. During observation, surveyors found an open metal box containing a disposable e-cigarette on the resident’s over-bed tray, and the resident and CNAs confirmed the vape was kept in the room despite staff acknowledging it was not permitted. The DON confirmed the resident was not allowed to keep e-cigarette supplies in the room, and review of the facility’s smoking policy showed all smoking materials, including vapes, were required to be stored in locked boxes at the nurse station or designated area.
A resident with dementia, quadriplegia diagnosis, behavioral issues, and documented fall risk had a care plan calling for a hazard-free room, use of a floor mat or mattress at bedside, and behavioral approaches to reduce injury from falls. Despite this, the resident—who was dependent for ADLs but able at times to scoot and push herself off the bed—experienced an unwitnessed fall, was found face down on the floor with head trauma, and may have struck a nearby tube feeding pole. Observations and staff interviews showed that equipment and furniture such as an oxygen concentrator, wastebasket, bedside table, and feeding pole were positioned near the bed where the resident, known to reach over the side and pull on nearby objects, could hit her head if she fell. The facility did not consistently implement the care-planned environmental and supervision interventions to keep the area free of accident hazards, resulting in a cited deficiency.
The deficiency involves multiple failures to implement ordered or care-planned fall-prevention measures and to conduct a complete post-fall investigation. Several residents with significant medical and functional impairments experienced falls or were identified as at risk, yet interventions such as non-skid floor strips, fall mats at bedside, Dycem on a wheelchair seat, and proper wheelchair foot pedals were not in place as ordered or documented by the IDT. In one case, a dependent resident was lowered to the floor during ADL care and sustained a skin tear, but the facility’s investigation did not clearly determine why the resident was lowered, who did so, or how the injury occurred, and staff accounts were contradictory. These events occurred despite a facility policy requiring prompt, detailed fall investigations and the identification and implementation of appropriate fall-prevention interventions.
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Supervise Resident Who Left on LOA With PICC Line and Recent Toe Amputations
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and safety interventions to prevent a resident from leaving the facility unsupervised and engaging in unsafe behaviors, despite known substance use history and medical vulnerabilities. The resident had been admitted following a hospitalization for bilateral lower extremity pain, osteomyelitis of two toes, and subsequent toe amputations, and was discharged from the hospital with a PICC line for IV antibiotics. Hospital records showed the resident had tested positive for amphetamines and cannabinoids prior to admission. On admission, the resident signed a Substance Use Disorder Program (Stepping Stones) consent that outlined safety measures including supervised visits, restricted visitation hours, random searches, and no LOA without collaboration with the counselor, IDT, and physician. The resident’s elopement assessment rated him as low risk, and his care plan documented a substance abuse disorder with an intervention that he would follow the Stepping Stones protocol. The resident’s admission assessments documented intact cognition with a BIMS score of 15, bilateral lower extremity impairment, use of a wheelchair or scooter, and a surgical wound on the right foot. Despite the Stepping Stones consent and the documented plan that the resident would follow the program protocol, the facility did not actually implement the program because there was no counselor available, and no additional supervision or interventions were added based on his needs. The Regional Director of Clinical Services confirmed that although the resident signed the consent and the care plan referenced following the Stepping Stones protocol, he was never actually placed on the program. The Admission Director stated she had informed the resident he was not allowed to leave without supervision, but also reported that the Administrator told the resident that if he could find a way to get his motorized wheelchair, he could do so. Staff interviews showed that multiple staff were aware the resident was focused on obtaining his power chair and was likely to leave, but there was confusion about his LOA status and no clear restriction or supervision was enforced. On the day of the incident, the resident signed himself out in the LOA book without verbally notifying staff and left the facility in a friend’s car to retrieve his motorized wheelchair. CNA staff knew he planned to leave to get his wheelchair but were unsure of the time and believed he did not have privileges to leave; the LPN on duty believed the resident was going to leave that day and later realized the resident had signed out by accessing the LOA book himself. The facility investigation documented that the police contacted the facility about someone having escaped, and staff reported the resident was on LOA and safe. The Admission Director communicated with the resident by cell phone while he was away and reported to the Administrator that he would be riding his wheelchair back, but the Administrator declined to have staff pick him up. The resident then traveled approximately five miles back to the facility in his motorized wheelchair, wearing regular clothes with a hospital gown, stopping at private and public locations, including a tavern, to charge the chair. Staff, including the ADON and LPN, were aware he was riding back unsupervised, and the physician later stated he would have preferred the resident sign out AMA if leaving without supervision due to the PICC line. The resident ultimately returned to the facility that evening, where he was assessed, but the deficiency centers on the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safety interventions to prevent the unsupervised departure and unsafe behaviors. Observation of the resident after the incident showed he had a PICC line in place, a surgical boot on his right foot, slightly unsteady gait, and a large motorized wheelchair in his room. The resident reported that he knew he was not supposed to leave unsupervised based on prior conversations with administration but chose to leave to obtain his chair. He stated he informed the facility while away and asked to be picked up, but was told they would not pick him up, requiring him to ride and at times push his wheelchair back, stopping multiple times to charge it. Staff interviews corroborated that the resident’s picture appeared on social media while he was out, that staff saw him in the community wearing a hospital gown over his clothing, and that the facility considered him to have signed out LOA because he had a BIMS of 15 and was alert and oriented. The Administrator later stated that because the Stepping Stones program was no longer offered, the resident did not have restrictions in place, despite the signed consent and care plan references. This sequence of events, combined with the lack of implemented safety measures and supervision, formed the basis of the cited deficiency under F689 for failure to ensure the environment was as free of accident hazards as possible and that the resident received adequate supervision to prevent accidents.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission or agreement by the provider of the truths of the facts alleged or correctness of the conclusions set forth on the statement of deficiencies. This plan of correction is prepared and submitted solely because of the requirements under the state and federal law. This plan of correction will serve as the Facility's allegation of substantial compliance and completion with an allegation of compliance date of 4/28/2026. Resident #2 no longer resides in the facility. On 4/23/2026 the Director of nursing/designee identified and interviewed all like residents with a BIMS 13 and higher to address any needs expressed of belongings needed outside of facility. No one identified any needs outside of facility. Director of Nursing/designee will educate all staff that if the any resident has any needs outside of the facility to fill out a concern form and give concern form to Social Service or Administrator to be addressed. This will be completed by 4/28/2026. Director of Nursing/designee will educate all staff to include LOAs, and will be completed by 4/28/2026. Residents requiring supervision for LOAs were reviewed on 4/23/2026 by Director of Nursing to ensure they are receiving appropriate supervision when needed. To ensure the deficient does not recur the Director of Nursing/designee will audit any new admissions for assistance with outside needs x 4 Weeks then continue compliance with daily room checks done by all department managers daily Monday thru Friday.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Unsecured E-Cigarette Supplies Kept in Resident Room
Penalty
Summary
The facility failed to ensure smoking supplies were locked and secured as required by facility policy and the resident’s care plan. One resident, admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acute and chronic respiratory failure with hypoxia, epilepsy, COPD, alcohol abuse, cannabis use, and tobacco use, had a quarterly MDS indicating intact cognition. The resident’s care plan, dated 02/13/26, identified risk for injury related to smoking, cigarettes, and electronic devices, with interventions specifying that the resident was to be supervised at all times while smoking, wear a smoking apron, and have all smoking items kept at the nurse station. During observation on 03/18/26 at 10:49 A.M., the resident was seen in bed with oxygen via nasal cannula, and an open red metal box containing a disposable e-cigarette (vape) was on the over-bed tray next to the bed. The resident confirmed that he kept the vape in his room in the red box. Two CNAs separately confirmed that the resident had his e-cigarette vape in his room, and one CNA stated he was not permitted to have it there. The DON also confirmed the resident was not permitted to keep e-cigarette supplies in his room. Review of the facility’s “Lionstone Smoking” policy, revised 10/15/24, showed that no smoking materials are permitted with the resident or in their room and that all smoking materials, including vapes, must be kept in lock boxes at the nurse station or designated area. This constituted non-compliance with the requirement to keep smoking materials secured.
Failure to Implement Care-Planned Fall and Hazard Controls for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain care-planned fall and accident-hazard interventions for a resident identified as being at risk for falls and injury. The resident was admitted with multiple diagnoses including unspecified dementia, quadriplegia, delusional disorders, early-onset Alzheimer’s disease, anxiety disorder, major depressive disorder, and epilepsy. On admission, the nursing evaluation identified the resident as at risk for falls, and the care plan documented fall risk related to impaired cognition and decreased safety awareness, with goals to reduce injury risk. Interventions included ensuring the room was free from accident hazards, placing a floor mat next to the bed, and later revising this to a mattress on the floor at bedside. The care plan also documented behavioral issues such as verbal aggression, yelling, throwing legs out of bed, resisting care, socially disruptive and attention-seeking behaviors, including a history of yelling fire and pretending to have seizures, with interventions to approach calmly and re-approach if agitated. The resident’s care plan further identified an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADLs, Alzheimer’s disease, and cognitive impairment, with documentation that the resident required one-person assistance for ADLs and a two-person assist with a mechanical lift for transfers. The MDS assessment indicated the resident was cognitively intact, had no impairment of upper and lower extremities, and was dependent for rolling in bed and transfers. Despite being care planned as dependent for mobility and at risk for falls, multiple interviews and observations established that the resident was able at times to move, scoot to the edge of the bed, and push herself off the bed. Staff, the POA, and the NP all reported that the resident could and did intentionally push or throw herself from the bed, sometimes to gain attention, and that she had a history of similar behaviors at a previous facility. The facility’s fall protocol required assessment of history of falls, cognitive/behavioral symptoms, mobility, and development and implementation of a plan of care to reduce falls and minimize injury. The incident underlying the deficiency included an unwitnessed fall in which the resident was found on the floor next to the bed after reportedly throwing herself out of bed, with a hematoma near the left eye and an active nosebleed, requiring EMS transport to the hospital. At the time of this fall, the resident had a fall mat on the floor and a tube feeding pole with a feeding machine next to the bed, and staff reported the resident might have hit her head on the pole. Subsequent observations showed the resident with bruising and steri-strips on her forehead, and later lying in bed leaning over the side with an oxygen concentrator, wastebasket, and bedside table positioned near her head. A CNA immediately identified and removed these items as accident hazards, acknowledging the resident was a fall risk who could hit her head on them if she fell. The DON later acknowledged the resident probably hit the cement floor when she rolled off the bed. These findings demonstrate that the care-planned interventions to keep the room free of accident hazards and to provide adequate environmental protection (such as appropriate placement of mattresses and removal of hazardous equipment and furniture near the bed) were not consistently implemented, resulting in a failure to ensure a hazard-free area and adequate supervision to prevent accidents for this resident. Additional interviews reinforced that the resident frequently reached over the side of the bed, grabbed and pulled on the floor mat, and pulled on nearby equipment such as the tube feeding pole. Staff, including the RN, CNA, NP, and DON, described the resident’s fluctuating physical abilities and behavioral components, including faked seizures, reports of chest pain, and self-propelling off the bed. Despite this known pattern and the care plan directive to keep the environment free of accident hazards and to use protective measures at bedside, the resident continued to have accessible objects and equipment within striking distance of her head while in bed. The facility’s failure to consistently remove or reposition these hazards and to fully implement the individualized fall and behavior-related interventions as care planned led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Implement Fall-Prevention Interventions and Complete Thorough Post-Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and to conduct a thorough post-fall investigation for multiple residents. For one resident with COPD, severe protein-calorie malnutrition, dysphagia, wheelchair use, and severe cognitive impairment, orders and care plan interventions for non-skid floor strips near the bed and fall mats on both sides of the bed were in place following recurrent falls. However, during observation of the resident’s room, there were no non-skid strips or fall mats at the bedside, and the LPN confirmed these items were not present. Another resident, cognitively intact and largely independent in ADLs except for needing substantial assistance with bathing, experienced a fall and had a post-fall intervention of nonskid strips to the floor documented in an IDT follow-up note. The resident’s fall risk care plan did not include nonskid strips as an intervention, and a separate care plan intervention for a visual reminder to ask for assistance when getting out of bed was not observed in the room on multiple occasions. Nursing staff confirmed that nonskid strips were not on the floor and that the visual reminder, which should have been posted near the bed and in the bathroom, was not in place. A third resident, cognitively intact with a history of cerebral infarction, hemiplegia, traumatic cerebral hemorrhage, heart disease, and alcohol abuse, had an unwitnessed fall after sliding from a wheelchair post-therapy. The IDT determined Dycem should be added to the wheelchair seat as a preventive intervention, but subsequent observation in the therapy department showed no Dycem on the wheelchair, and therapists confirmed its absence despite one therapist stating she had previously placed it. For a resident with anoxic brain damage, COPD, dysphagia, bilateral hand contractures, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and severely impaired cognition, the plan of care identified fall risk and dependence for rolling and other ADLs. A progress note documented that the resident was lowered to the floor during ADL care by a CNA and sustained a skin tear to the right side of the back. The fall investigation concluded that a hospice aide was providing care when the resident fell out of bed and that the suspected root cause was the air mattress and turning the resident, but the investigation did not identify why the resident needed to be lowered to the floor, who lowered the resident, or how the skin tear occurred. The DON later stated that both a hospice aide and a facility CNA were present, that staff accounts were contradictory, that only one witness statement from a unit manager was available, and verified that it remained unclear what happened and how the skin tear was obtained, confirming that a thorough investigation was not completed. Another resident with intact cognition, major depressive disorder, borderline personality disorder, seizure history, and other psychiatric and pain-related diagnoses was care planned as being at risk for falls due to new admission status, potential medication side effects, and seizure history. After the resident fell from bed during a seizure and was found on the floor at bedside, the IDT added fall mats to both sides of the bed as an intervention. On two separate observations, the resident was in bed without fall mats in place, and the DON confirmed that the fall mat intervention ordered after the first fall was not in place. A further resident, cognitively intact with an above-knee amputation, polyneuropathy, muscle weakness, and muscle wasting, fell forward out of a wheelchair while being transported by a company driver to a van for dialysis, with the right leg caught in the wheelchair wheel. The IDT follow-up identified the cause as the absence of the right foot pedal and initiated an intervention that the right foot pedal be in place when the resident was transported. The therapy manager stated that residents with wheelchairs are always given foot pedals, that this resident always used foot pedals, could not remove the pedal independently, and could not self-propel, and the DON confirmed the fall occurred when the resident did not have the right foot pedal on the wheelchair when leaving for dialysis. The facility’s fall prevention and management policy stated that the facility would identify risk factors to minimize falls, obtain information from assessments, diagnoses, and current ADL status, and begin a fall investigation once the resident was safely transferred following a fall. The policy required asking the resident what they were doing when they fell, identifying witnesses and obtaining written statements immediately, attempting to identify why the resident fell before implementing post-fall interventions, and conducting an interdisciplinary review with discussion of the fall, potential causes, existing interventions, and a deep root cause investigation. The findings show that for multiple residents, ordered or care-planned fall-prevention interventions such as non-skid strips, fall mats, Dycem, and wheelchair foot pedals were not in place at the time of observation or transport, and for one resident, the post-fall investigation did not meet the facility’s own policy requirements for a thorough and clearly documented investigation.
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