Failure to Maintain a Safe Environment and Prevent Accident Hazards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision in the facility, affecting several residents with varying degrees of cognitive and physical impairment. In several instances, floor mats intended to reduce injury from falls were obstructed by heavy objects such as overbed tables and visitor chairs, as observed in the rooms of residents with documented fall risks and impaired cognition. Staff interviews confirmed that these items should not have been placed on the mats, as this could compromise their effectiveness in preventing injury during a fall. Additionally, a bedside table was found on top of a fall mat in another resident's room, with staff acknowledging this practice was unsafe. Other environmental hazards were also documented, including an uncovered electrical outlet behind a resident's bed and a broken baseboard with exposed nails in another resident's room. Staff admitted to being aware of these hazards but failed to report them, and maintenance personnel confirmed that such conditions were unsafe and not in compliance with facility policy. The presence of these hazards was corroborated by direct observation and staff interviews, and facility policies reviewed by surveyors required immediate reporting and correction of such issues to maintain a safe environment. Additional deficiencies included improper storage of cigarettes and medications. A resident was found with a pack of cigarettes in their possession, contrary to facility policy requiring secure storage of smoking materials. Medications, including topical creams and eye drops, were left at the bedside of two residents without proper physician orders or secure storage, in violation of facility procedures. Staff interviews confirmed that these practices were not in line with established protocols and posed risks as outlined in the facility's own policies and procedures.