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F0689
E

Unsecured Hazardous Items Accessible to Cognitively Impaired Residents

Dubuque, Iowa Survey Completed on 07-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that hazardous items were securely stored and inaccessible to residents, as required by facility policy and chemical safety guidelines. During observation, an unattended utility cart with open shelves was found outside an occupied room, containing deodorant spray, disinfectant wipes, and three pairs of pointed-edged scissors. These items were labeled to be kept out of reach of children and should have been locked away. Staff confirmed that the facility policy required such items to be locked up, but the cart was left unattended and accessible. Additionally, a container of disinfectant wipes was observed unsecured on a shelving unit in a lounge area accessible to all residents. Staff interviews and clinical record reviews identified that residents with severely impaired cognition, as indicated by low BIMS scores, frequently wandered in these areas. The Director of Nursing confirmed that multiple residents who wandered and had cognitive impairments had access to these unsecured hazardous items, in direct violation of the facility's chemical storage policy.

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