F0689

E

Failure to Control Environmental Hazards and Implement Safe Transfers and Fall-Prevention Measures

Joliet, Illinois Survey Completed on 12-12-2025

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents. Housekeeping staff left an unsecured cleaning cart in a resident hallway containing an 8 oz bottle labeled as dermal wound cleanser but actually filled with glass cleaner, a generic spray bottle containing bleach, and a quart bottle of pine cleaner. The housekeeper reported that she had retrieved the wound cleanser bottle from the trash and refilled it with glass cleaner after her original bottle broke, and that the generic spray bottle contained bleach. The cart had no locked compartment, and the facility’s housekeeping policy did not provide direction on proper storage or use of hazardous cleaning products. Safety Data Sheets for the chemicals described risks such as skin irritation, serious eye damage, respiratory irritation, and harm if swallowed.

The facility also failed to ensure safe transfer techniques were used for a resident with significant physical and cognitive impairments. A CNA was observed transferring this resident from bed to a high-back wheelchair by placing a hand under the resident’s arm, holding the waistband of the pants, and pulling the resident to stand and pivot without using a gait belt. Interviews with the restorative nurse, restorative CNA, and DON confirmed that staff were expected to use gait belts for transfers and not to pull residents by their waistbands. The resident’s diagnoses included hemiplegia and hemiparesis affecting the right dominant side, chronic pain, failure to thrive, repeated falls, and altered mental status. The MDS showed the resident required substantial assistance for sit-to-stand and chair-to-bed transfers, and the care plan documented a history of falls related to poor safety awareness and impulsive behavior, with interventions specifying extensive assist by two staff and use of a mechanical lift with two staff for certain transfers.

Additional deficiencies were identified in the use of fall mats and implementation of fall-prevention interventions. Two CNAs transferred a resident with hemiplegia and moderate cognitive impairment from a wheelchair to bed using a mechanical lift while fall mats remained down on both sides of the bed; the lift was rolled over the fall mat to position the resident in bed. The restorative nurse and DON stated that fall mats should be moved prior to transferring residents back to bed because they interfere with proper positioning of the lift base under the bed and present a tripping hazard. For two other residents at high risk for falls, the facility did not implement care-planned positioning and seating interventions. One resident of shorter stature, with a history of four falls in front of his wheelchair, was repeatedly observed in a specialized high-back chair without leg rests or footrests, leaving his legs dangling and unsupported and in slouched or unsafe positions, including sitting across the seat with legs over the armrest while nursing staff did not assist with repositioning. Another resident, also with four recent falls in front of a specialized high-back chair, was observed multiple times in a high-back chair or wheelchair without the care-planned non-slip seating material and with feet dangling due to missing footrests. Staff acknowledged that these residents were frequent fallers and that specific fall interventions, including non-slip devices and safe positioning, were expected to be implemented based on posted communication sheets and updated care plans.