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F0689
E

Failure to Secure Hazards and Complete Smoking Assessment

Holton, Kansas Survey Completed on 08-26-2025

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

The facility failed to secure hazardous areas and materials, including an unlocked closet containing electrical panels and an unlocked cabinet with a razor and cleaning chemicals, despite the presence of eight cognitively impaired, independently mobile residents. Observations revealed that the electrical panel closet remained unsecured over multiple days, and staff members, including licensed nurses, housekeeping, and maintenance, were unsure or unaware of the requirement to keep these areas locked. Additionally, a shower room cabinet containing potentially dangerous items was found with the padlock open and the key left in the lock, and hazardous products were left out in the open. The facility's own policy required the environment to be as free of accident hazards as possible, but this was not followed. The facility also failed to assess a resident with multiple diagnoses, including hemiparesis, aphasia, bipolar disorder, dysphagia, anxiety, depression, and vascular dementia, for smoking safety. The resident's care plan noted that smoking was a favorite activity, but there was no current smoking assessment in the electronic medical record, and staff could not provide one when requested. The resident was observed requesting to go outside to smoke on several occasions, and staff interviews confirmed that smoking assessments were expected to be completed but were not present for this resident.

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