Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for residents by not securing accident hazards and not providing adequate supervision. Surveyors observed an unsecured and hot steam table in the North Wing Dining Room, with both entry doors open and unlocked, allowing residents unrestricted access to the steam table during meal service. Staff interviews confirmed that the steam table remained on and hot throughout breakfast and lunch, and the door meant to separate residents from the steam table was not consistently closed or locked. Additionally, two restrooms in the main hallway were found to lack emergency call cords near the toilets, despite being accessible to residents. Further deficiencies were identified regarding the storage of hazardous chemicals. On the Happy Trails unit, an unlocked cabinet in the dining/activity room contained a spray bottle of odor eliminator, and in the North Wing dining room, another unlocked cabinet contained a bottle of ant, roach, and fly spray. Both cabinets were accessible to residents at the time of observation. The DON acknowledged that these cabinets should have been locked to prevent resident access to hazardous substances. The facility also failed to provide required one-to-one supervision for a resident with a history of behavioral disturbances, including aggression and exit-seeking behaviors. Staff assigned to supervise the resident left the resident unattended in their room, contrary to physician orders and the resident's care plan, which called for continuous one-to-one supervision. The DON confirmed that staff should have remained within sight and close enough to intervene as needed. The resident's record indicated a history of agitation, aggression, and a prior incident of resident-to-resident abuse.