Multiple Failures in Accident Prevention, Supervision, and Elopement Safeguards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision throughout the facility. Hot water temperatures in resident rooms were found to be excessively high, ranging from 121.7 to 145.5 degrees Fahrenheit, well above the safe range of 105-115 degrees as stated by the Maintenance Director. Residents with varying degrees of cognitive impairment and physical limitations were exposed to these hazardous water temperatures, with some residents reporting the water was hot enough to make noodles. The facility's water temperature logs over the previous six months did not reflect these high temperatures, instead showing much lower readings, and discrepancies were noted between the surveyors' thermometers and the facility's infrared thermometer during testing. In addition to the water temperature issue, the facility failed to provide adequate supervision for residents who required it while smoking. Several residents who were assessed as needing supervision were observed smoking unsupervised in various locations, including outside the facility and near the sidewalk. Some residents kept their own smoking materials despite care plans and evaluations indicating that these should be stored by staff and only used under supervision. There were inconsistencies in the facility's smoking policy implementation, with staff interviews revealing confusion about which residents required supervision and how smoking materials were managed. One resident was not properly evaluated for smoking, and the list of supervised smokers was outdated. The facility also failed to prevent elopement for residents assessed as being at risk. Two residents with significant cognitive impairment and histories of wandering were able to leave the facility without staff knowledge. In one case, a resident was found walking two blocks away and returned by a CNA, while another resident was found by police after leaving the facility and becoming combative. The facility's elopement prevention measures, such as wander guards, were not effective in preventing these incidents, and staff were unsure how a resident was able to exit the building while wearing a wander guard. Additional hazards were noted, such as a non-functioning front doorbell that left residents locked outside and unable to alert staff, and the storage of metal bed frames and boxes in a dayroom occupied by residents.