Unsecured Hazardous Chemicals and Failure to Honor Restricted Liquid Diet
Penalty
Summary
The facility failed to maintain a safe environment free of unsecured hazardous chemicals, as evidenced by observations of unlocked storage areas containing potentially poisonous substances. Specifically, a shower room closet in one unit was found to be easily unlocked and contained a bottle labeled as a chemical cleaner with a warning to keep out of reach of children. In another unlocked shower room, a gallon-sized container with a nozzle sprayer and tubing, containing an unidentified clear liquid, was found on the floor without any labeling. The Maintenance Director confirmed that these chemicals should have been secured and properly labeled, and was unable to identify the contents of the unlabeled container. During the same period, a resident with severe cognitive impairment and a history of wandering was observed moving freely throughout the facility, including the areas where these unsecured chemicals were accessible. Additionally, the facility failed to honor a restricted liquid diet for a resident reviewed for hydration. The report notes that the facility did not ensure the resident received the appropriate diet as ordered, which is required to maintain proper hydration and health. The resident's medical record indicated the need for a restricted liquid diet, but this was not provided as specified during the survey period.
Plan Of Correction
F689 The facility failed to maintain an environment free from accident hazard when unsecured cleaning chemicals were observed in the B Wing Shower Room and in a closet outside of the A Wing Shower Room. Step 1: The facility DOM immediately removed the chemicals from the B Wing Shower Room and placed a lock on the closet outside of the A Wing Shower Room. Completed on 6/10/25. Step 2: This has the potential to affect 3 residents, #37, #14, and #4, who are known to wander throughout the facility. The facility DON assessed and identified residents with no negative findings. Completed on 6/11/25. Step 3: To prevent this from reoccurring, the DON or designee will educate staff on the need to keep chemicals in a secure location when not in use. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit shower rooms and closets 3 times per week for 4 weeks, then monthly for 2 months, to ensure cleaning chemicals are secure. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.