Failure to Maintain Hazard-Free Environment and Adequate Supervision Resulting in Severe Injuries
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment and provide adequate supervision, resulting in serious injuries to two residents. One resident with Alzheimer’s disease, dementia, insomnia, palliative care, restlessness, agitation, and a history of falls had a BIMS score of 7, indicating severely impaired cognition. Her care plans documented poor balance, decreased strength, impaired ambulation, limited mobility, and the need for substantial/maximal assistance with bed mobility and transfers, including one‑person assistance and mechanical lift designation. She was also on hospice for end‑stage Alzheimer’s disease, required total care with ADLs, was nonverbal or minimally verbal, impulsive, frequently attempted to get up on her own, and was considered at high risk for falls. On the night of the incident, the resident’s bed was a low bed positioned near a floor radiator heater. The CNA assigned to her shift from 11:00 p.m. to 7:00 a.m. stated she did not complete required two‑hour rounds, admitting she initially rounded at the start of the shift and then not again until approximately 4:45–5:00 a.m. She reported that the privacy curtain around the resident’s bed was pulled fully across and that she did not see the resident at all during the shift prior to discovering the fall. The CNA and another CNA had spent about 30 minutes assisting another resident back to bed, after which the assigned CNA focused on documenting point‑of‑care tasks instead of rounding. The CNA acknowledged she was negligent in not doing her rounds and stated that the resident was confused, tried to get up all the time, and was not steady on her feet. Around 5:15 a.m., the CNA called the LPN/charge nurse into the room, where the resident was found lying on her right side between the bed and the wall, directly on the exposed floor radiator heater with the heater cover off. The LPN and CNA assisted the resident back to bed and noted blistered areas on the right shoulder and right hip. Facility internal documentation and hospital records described multiple intact and burst blisters, areas of pink flesh, charred skin, subcutaneous tissue exposure, and deep burns down to and through deltoid muscle, requiring debridement and split‑thickness skin grafts to the right upper and lower extremities. The LPN reported that she had last seen the resident around 3:00–3:15 a.m. sleeping, while the CNA stated she had not seen the resident at all before the incident. Staff interviews indicated that the radiator heater cover in this room had been loose or coming off for months, with multiple staff (a CNA and an LPN) stating the cover was in disrepair and would come off prior to the incident, and the CNA stating the cover had been off for over nine months. The facility’s Administrator acknowledged that at the time of the incident the radiator cover in the resident’s room was not attached and believed it came off when the resident fell out of bed. However, the CNA and another CNA reported that the radiator cover had been loose or off for an extended period before the incident, and an LPN stated it had been that way for at least a couple of months, despite housekeeping cleaning the room daily. The Maintenance Director confirmed there had been no documented protocol or regular documentation of radiator heater checks prior to the incident and that only hot water and common area temperatures were being monitored. He also confirmed that two screws on each end were needed to secure the heater covers and that the resident was thin enough to fit between the radiator and the floor. These combined failures—lack of timely supervision/rounding for a cognitively impaired, high‑fall‑risk resident and failure to identify and correct a known physical hazard (an unsecured radiator heater cover adjacent to the resident’s bed)—led to the resident’s prolonged contact with the uncovered heater and the resulting severe burn injuries. The deficiency also involved another resident who suffered a laceration to the left eye requiring sutures and traumatic subdural hematomas that required ICU admission and ultimately resulted in hospice admission due to the subdural hematoma. This second resident was one of four reviewed for hazards/supervision and was noted in the deficiency statement as an additional example of the facility’s failure to provide a hazard‑free environment and adequate supervision to prevent accidents. The report attributes both residents’ injuries to the facility’s failure to ensure the environment was free from accident hazards and to provide sufficient supervision to prevent accidents.
Removal Plan
- Visited all resident rooms on all units and rearranged beds as necessary to ensure no beds are pushed against walls or close to heating units.
- Placed bedside cabinets/nightstands between the bed and the wall that houses the floor radiator to provide separation from bed to wall; continued monitoring with education provided to residents who resisted.
- Removed R1’s bed from the wall and heating unit.
- In-serviced on-duty nursing staff and housekeepers that no resident beds are to be pushed to walls or close to heating units and that bedside cabinets/nightstands are to be placed between bed and wall radiators.
- Provided verbal education to staff on safety protocol covering: not positioning beds against walls; not positioning beds close to heating units; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; use of bedside cabinets/nightstands as separation; and fall prevention program.
- Discussed the R1 incident with the IDT as an impromptu QAPI with instructions to increase visual rounding on all units and scheduled follow-up discussion at the next QAPI.
- In-serviced staff on hourly rounding and implemented an hourly rounding form.
- In-serviced nurses and CNAs verbally on: not positioning beds against walls; not positioning beds close to heating units; placing bedside cabinets/nightstands between bed and wall radiators; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; and fall prevention program.
- Implemented a system for preventive maintenance rounds in all resident rooms: Maintenance Director and Assistant Director perform rounds daily when on duty; on weekends, each housekeeper performs rounds on assigned units; needed repairs reported immediately; if a potentially harmful repair cannot be completed immediately, resident will be placed in an alternate room until repair is completed.
- Checked heating units for secure protective coverings, with ongoing daily monitoring by Maintenance Director/assistant and weekend housekeepers.
- Initiated hourly rounding with recordings on all units.
- Assigned oversight/monitoring responsibilities for compliance during routine daily rounds; in their absence, Charge Nurse, Facility Manager on Duty, and assigned weekend housekeepers monitor compliance.
- Brought the event to the monthly QAPI meeting for discussion and re-evaluation of interventions, with additional interventions to be implemented if needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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